Deficiencies in Person-Centered Care Plans
Penalty
Summary
The facility failed to provide person-centered care plans for two residents, leading to deficiencies in addressing their specific medical and psychosocial needs. One resident, who was cognitively intact, was admitted with diagnoses including Post-Traumatic Stress Disorder (PTSD) and Vascular Dementia. However, their care plan did not include provisions for these conditions. The social worker acknowledged the absence of a care plan for these diagnoses after being questioned by the surveyor, and the Nursing Home Administrator confirmed that appropriate care plans and psych services should have been in place. Another resident, who had moderate cognitive impairment and was dependent on assistance for most activities of daily living, was observed without heel protectors despite having a pressure ulcer on the right heel. This resident often refused care and did not adhere to their Renal Diet, leading to elevated potassium and phosphorous levels. Despite these issues, there was no care plan addressing the resident's non-compliance. Interviews with staff and family confirmed the resident's frequent refusal of care and dietary non-adherence, yet the facility's Behavioral Care Services policy, which includes care plan development, was not followed.
Plan Of Correction
Element 1: It is the practice of the facility to provide person-centered interventions and care plans for patients with Vascular Dementia, PTSD, and ESRD. R78 and R46 care plans have been reviewed and updated. Element 2: Residents that have been diagnosed with Vascular Dementia, PTSD, and ESRD have the potential to be affected by this cited practice. Those residents' care plans have been reviewed and updated. Element 3: The Interdisciplinary Team reviewed the policy and procedure to Develop/Implement Comprehensive Care Plan and deemed it appropriate. The Social Services and dietician have been educated on the policy of Develop/Implement interventions and care plans with focus on to provide person-centered interventions and care plans. Element 4: S.W./Designee will audit new admissions with diagnoses of Vascular Dementia, PTSD to ensure care plans are in weekly x4 then monthly x3. Dietician/Designee will audit renal patients to ensure non-compliance diet care plans are in place and will do random audits on renal patients for compliance with diet weekly x4 weeks then monthly x3 months. Results of audits will be taken through QA for further review and recommendations. The Administrator will be responsible for sustaining compliance.