Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to update the care plan for a resident following an incident involving inappropriate behavior. The resident, who had a history of self-exposure, was involved in an event where they were observed performing an inappropriate act on another resident. Despite this behavior being documented, the care plan was not updated to include individualized interventions to address these behaviors or prevent future incidents. The resident's medical history included diagnoses such as wasting and atrophy, major recurrent unspecified conditions, and unspecified severity without behavioral disturbance. The resident had documented behaviors of self-exposure that were not incorporated into the care plan prior to the incident. The care plan only included general interventions for self-exposure, such as encouraging appropriate expression of feelings and providing opportunities for positive interaction, but lacked specific strategies to address the recent event. Interviews with staff revealed a lack of awareness and communication regarding the resident's history of exposing themselves. The Advanced Practice Registered Nurse (APRN) was not aware of the resident's history of such behaviors prior to the incident. The Nursing Home Administrator (NHA) also admitted to not reviewing previous records that documented the resident's behavior. This lack of communication and failure to update the care plan contributed to the deficiency in addressing the resident's needs and ensuring their highest practicable well-being.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider for the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. **Develop/Implement Comprehensive Care Plan** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Facility updated Care Plan of resident #1 on How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: 1. On, in-house quality review was completed to ensure residents exhibiting behaviors have accurate and updated care plans with a focus of ensuring a person-centered approach with resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental needs that are identified in the comprehensive assessment. Any outstanding issues or concerns were addressed as they were identified. What measures will be put in place or what systematic changes you will make to ensure that the practice does not recur: 1. On, the Regional Director of Clinical Services in-serviced the Interdisciplinary Team (IDT) on the components of this regulation and the facility policy regarding plans of care with an emphasis on person-centered care. 2. Facility staff were reeducated by the Assistant Director of Nursing/designee on Plans of Care policy and procedure with an emphasis on person-centered care. 3. Newly hired employees and contract staff will receive education during orientation. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: During Morning meeting, the Director of Nursing (DON) and/or designee will review occurrence of behaviors documented from previous day, and/or post psychiatry documentation review, to ensure Care Plans are updated accordingly, daily 5 times a week for 4 weeks, then weekly for 4 weeks, then random Care Plans every other week, to ensure Care Plans are person-centered and accurate, until the QAPI committee finds that the facility has met substantial compliance. Date Certain: