Care Plan Deficiencies in Resident Code Status and Safety Measures
Penalty
Summary
The facility failed to develop, implement, and revise care plans to meet the needs and preferences of three residents. For Resident #5, the care plan did not accurately reflect the resident's code status as decided by the healthcare representative. Despite the MDS coordinator documenting the representative's decision, the care plan was not updated, and the error was not caught by the Social Services Director. The Director of Nursing confirmed the care plan was inaccurate and did not reflect the resident's representative wishes. Resident #8's care plan also had deficiencies. The resident's son, who was involved in healthcare decisions, was not consulted about the resident's code status during the care conference. The care plan and physician's order incorrectly listed the resident as a full code, despite the resident and her son indicating otherwise. There was no documentation showing the resident's son was included in the development of the care plan for advance directives. For Resident #12, the care plan did not include the use of mats to minimize injury, despite being requested by the resident's daughter. The care plan also failed to specify the need for two staff members for toileting, which was necessary due to the resident's fluctuating abilities. CNA Staff B, who was assisting the resident, was not aware of the requirement for two staff members and had not been trained to access the Kardex for resident information. The Assistant Director of Nursing confirmed that the care plan interventions were not implemented as required.
Plan Of Correction
1. Resident #5, #8, and #12 care plans were updated to reflect code status, ADL needs, precautions, and toileting protocols. 2. Audit of all care plans initiated and completed. 3. IDT members re-educated on timely care plan development and revisions. 4. Weekly audits for 4 weeks, then monthly for 3 months; reviewed in QAPI, led by MDS Coordinator or designee. 5. Report to QA committee will continue monthly for recommendations and or revisions. Correction completion date: