Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific care needs. For one resident, who was cognitively impaired and required assistance for daily care needs, there was no documented care plan to address the management of her colostomy. This oversight was confirmed by the Nursing Home Administrator during an interview, acknowledging that a care plan should have been in place for the resident's colostomy care. Another resident, who was cognitively intact and had a diagnosis of diabetes, did not have a care plan developed to address her diabetes management or the use of a continuous glucose monitoring system. Despite having physician orders for the use of a Freestyle Libre 3 sensor, there was no documentation of a care plan to support her treatment needs. This lack of documentation was also confirmed by the Nursing Home Administrator, indicating a failure to provide individualized care planning for the resident's diabetes management.
Plan Of Correction
Resident 40's care plan was updated to include the presence of an ostomy and interventions to address the care and maintenance. Resident 55's care plan was updated to include Diabetes Mellitus and the use of a continuous glucose monitor. Facility-wide sweep was conducted to capture other residents who have colostomies and diabetes and their care plans to ensure that colostomy status, diabetes mellitus and continuous glucose monitoring have been included with interventions in the care plans. Any issues identified were corrected at time of discovery. The registered nurse assessment coordinator (RNAC) and licensed nursing staff were re-educated on the need to update the comprehensive care plan accurately and timely when resident changes occur. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that the care plan updates are completed timely weekly X4 weeks, then monthly fX2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.