Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, which is a requirement under §483.21(b). Resident R37, who was admitted with a diagnosis of diabetes, did not have a care plan addressing this condition, despite having orders for insulin and Accu-Cheks multiple times a day. The Director of Nursing confirmed the absence of a care plan for diabetes management for this resident. Resident R115, admitted with a diffuse traumatic brain injury, had a physician's order for oxygen therapy as needed, but the comprehensive care plan did not include this therapy. The Director of Nursing confirmed the lack of a care plan for oxygen therapy. Similarly, Resident R136, who was prescribed Seroquel for psychotic disturbances, did not have a care plan addressing the use of this antipsychotic medication, as confirmed by the unit manager. Resident R75, diagnosed with bipolar disorder and anxiety disorder, was on multiple medications for these conditions, yet there was no care plan for these behavioral health diagnoses. The Assistant Director of Nursing confirmed this omission. Additionally, Resident R97, who had moderate cognitive impairment and a diagnosis of non-Alzheimer's dementia and depression, did not have a care plan addressing their mood disorder, despite a psychiatric assessment indicating feelings of anxiety and depression.
Plan Of Correction
1. Resident R-37 has a care plan in place for Diabetes. Resident R-115 has a care plan in place for respiratory needs. Resident R-97, R-75, and R-136 have care plans in place for use of Psychotropic medications. 2. All residents with diagnosis of Diabetes, use of Psychotropic medications, and respiratory needs will have a comprehensive care plan with interventions to address resident care needs. 3. Nurse Educator/Designee will re-educate the professional nursing staff on the policies, "Care Plan Comprehensive Person-Centered, Diabetes, and Psychotropic Medication." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure residents with diagnosis of Diabetes, Respiratory needs, or use of Psychotropic Medications have a comprehensive care plan with interventions to address their care needs in place. 5. Audit results will be reviewed monthly by QAPI Committee.