Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for Resident #83, as required by the regulation. The care plan did not adequately describe the resident's medical, physical, mental needs, and preferences, nor did it outline how the facility would assist in meeting these needs. Resident #83, a male with a history of significant medical conditions including limitations in range of motion (ROM) on both sides of the lower extremities and one side of the upper extremity, was observed without necessary positioning devices or interventions to assist with his condition. Despite being on hospice services, there was no documentation or care plan addressing his ROM limitations or the use of supportive devices like pillows. Interviews with facility staff, including the Director of Rehab, Registered Nurse (RN) Staff B, and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding the resident's needs and the absence of a restorative program. The Care Plan Coordinator confirmed that there were no interventions documented for the resident's lower extremity limitations, and the resident's refusal of care was not properly documented. The deficiency was further highlighted by the absence of a care plan addressing the resident's ROM limitations, despite the resident's significant change in condition being noted in the Minimum Data Set (MDS) assessment.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #83 care plan was updated to reflect resident current status. B. Education for F656 provided to RN staff B, care plan coordinator Staff L and Care plan coordinator RN staff H. C. Director of Rehab is no longer at the facility. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with contractors and limited ROM was conducted and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F656. B. Nursing management will review 24 hour report and follow up on any new limited ROM or contractors and update care plan as needed. C. All New residents will be reviewed and reassessed if needed and review by the IDT team the following business day for any limited ROM or contractors to ensure appropriate interventions are in place. D. Education on F656 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Care Plans/Designee will audit new residents' charts and any change of condition charts to ensure that care plans are appropriate to reflect the status of the resident with emphasis on contractor or limited ROM weekly for four weeks then monthly for one quarter. The Director of Care Plans/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.