Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. Resident 29, who was admitted with chronic obstructive pulmonary disease, asthma, MRSA infection, type 2 diabetes mellitus with hyperglycemia, and cellulitis, was observed using a CPAP machine without an order, assessment, or care plan in place. Additionally, there was no care plan for the administration of Humulin R, a hypoglycemic medication, for Resident 29, despite the resident being on a high-risk drug class. The lack of care plans for these treatments meant that staff were not guided on the safe use and monitoring of these interventions, potentially compromising the resident's care. Resident 73, who was admitted with a flaccid neuropathic bladder, chronic viral hepatitis C, and acute respiratory failure, was prescribed Cephalexin, Ciclopirox, and Lotrimin AF cream. However, there were no care plans developed for these medications, which are crucial for monitoring side effects and ensuring safe administration. The absence of care plans for these medications indicated a failure to communicate the necessary interventions and goals to the healthcare team, which could affect the resident's treatment outcomes. Resident 52, diagnosed with type 2 diabetes mellitus with hyperglycemia and dysphagia, was receiving Insulin NPH without a corresponding care plan. This oversight meant that the staff lacked guidance on the safe administration and monitoring of the insulin, which is critical for managing the resident's diabetes. Additionally, Resident 97, who expressed a preference for only female CNAs due to fear of male caregivers, did not have this preference documented in a care plan. This lack of documentation led to a failure in respecting the resident's preferences, which could negatively impact their psychosocial well-being.
Plan Of Correction
Social Services provided a list of residents with known preferences for a specified gender of caregivers on 3/18/2025. Copies of the audits were provided to the DON for further review and analysis. A total of 65 residents' records were analyzed. The IDT developed and implemented person-centered care plans for 9 of 65 residents who required person-centered care plans for use of insulin, CPAP therapy, or who had expressed preferences for a specified gender of certified nurse assistant. Residents identified without interventions specific to CPAP, use of insulin, and preferences for specified caregivers. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Nursing/designee will re-educate the licensed nurses and IDT on or before 3/20/2025, re: the facility policy and procedure "Develop - Implement Comprehensive Care Plans," to ensure the development of a person-centered care plan is completed with person-specific interventions to address use of CPAP machines, use of insulin, and known preference for a specific gender of certified nurse aides. The interdisciplinary team will review the care plans of newly admitted residents and residents with physician order changes from the prior business day during the clinical meeting to ensure care planning for the preference for the use of insulin, CPAP machines, and known preferences for gender-specific certified nurse aides are developed and implemented to ensure staff have guidelines to care for residents. D. How the facility plans to monitor its performance to make sure solutions are sustained; The interdisciplinary team, led by the MDS Coordinator, completes a discipline-specific assessment of each resident at the time of admission to ensure person-centered care planning is present; to provide appropriate monitoring interventions. Care plans will be monitored and updated to reflect current interventions on admission, within 21 days, quarterly, annually, with significant change, as indicated. The MDS Coordinator/designee will report trends identified in the interdisciplinary team audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025.