Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop an individualized care plan for two residents, leading to deficiencies in addressing their specific needs. Resident #11, who has a history of PTSD, was observed reading a book in a wheelchair and did not respond to an interview attempt. Her roommate mentioned that she is hard of hearing and does not wear hearing aids. Despite having a care plan that included PTSD as a diagnosis, the plan lacked specific interventions related to her triggers and preferences for care. Staff members, including a CNA and the Social Services Director, were unaware of the resident's PTSD triggers, and the care plan did not include individualized interventions to address her trauma history. Resident #9, diagnosed with end-stage renal disease and dependent on dialysis, also had an incomplete care plan. The care plan failed to specify the location of the dialysis shunt and the dialysis center details, which are critical for managing potential complications related to hemodialysis. The MDS Coordinator acknowledged missing updates to the care plan, which should have been individualized and updated as needed. The Director of Nursing confirmed that care plans should be individualized and updated to reflect the resident's needs and conditions. The facility's policies and procedures emphasize the importance of comprehensive, person-centered care plans that include measurable objectives and timeframes. However, the care plans for both residents did not meet these standards, as they lacked specific interventions and updates based on the residents' conditions and needs. The interdisciplinary team is responsible for developing and implementing these care plans, but the deficiencies indicate a failure to adhere to the facility's policies and procedures.
Plan Of Correction
1. The care plan for resident #11 was updated to include interventions related to approach and determining her preference for care by MDS director on. Care plan for resident #9 was updated to include information regarding what center the resident goes to for by MDS director on. 2. MDS director or designee will complete quality assurance checks on resident care plans to ensure they include individualized goals and interventions by. 3. Reeducation was provided to the IDT team that resident care plans must be individualized with goals and interventions. 4. Quality assurance checks will be conducted of four random residents' care plans by the MDS director or designee 3 times a week for 6 weeks, then weekly for an additional 6 weeks to ensure they are individualized with interventions and goals. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.