Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #3, who had severe cognitive impairment and a history of falls, did not have a care plan that included the use of multiple mattresses in their room as a fall prevention measure. Despite the presence of these mattresses being a daily safety precaution, it was not documented in the care plan, and staff were unaware of its inclusion. Resident #9, who had intact cognition and chronic bilateral lower extremity edema, did not have a care plan that included the physician-ordered intervention of wrapping their legs with ACE bandages. Although the resident and staff confirmed the daily application and removal of the bandages, this intervention was not documented in the care plan, leading to a lack of formalized care planning for this medical condition. Resident #19, who was cognitively intact and had vision problems, did not have a care plan addressing their vision needs or the use of glasses. The resident reported difficulty with vision and the need for an ophthalmology appointment, which had not been scheduled since their admission. The facility's failure to coordinate follow-up specialist visits and update the care plan to include vision care needs contributed to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those identified: Resident #3- Identified and implemented a care plan for Falls was identified and implemented. Interventions have been initiated to reflect current approaches in plan to ensure safety. Resident #9- Reviewed and updated care plan for [MEDICAL CONDITION]. Interventions have been added to care plan to reflect approaches currently in place to ensure patient centered care and current needs. Resident #19- Identified and implemented a care plan for Vision. Interventions have been added to reflect current needs. Identification of other residents and corrective action: Every resident has potential to be affected by this deficient practice. All care plans for each resident will be audited for accuracy, correct those needed and to ensure all needs are addressed. Measures and Systemic Changes: The Interdisciplinary Care Plan Committee Policy was reviewed and updated appropriately. Education will be provided to staff regarding the changes in policy and for the process of completion of the care plan for each resident to ensure the care plan is person centered for each individual. Monitoring: All care plans will be audited weekly following the care plan meeting schedule. All care plans will be reviewed at least once within a 90 day period. This will be audited weekly for 3 months consecutively. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Ann(NAME) Mogensen, Director of Nursing by 3/31/25