Failure to Review and Revise Care Plan for Resident with Physical Restraints
Penalty
Summary
The facility failed to ensure the interdisciplinary team (IDT) reviewed and revised the comprehensive care plan for a resident with multiple physical restraints. The care plan for the resident, who was admitted with conditions such as spondylosis, osteoarthritis, and anxiety disorder, was last revised on 8/19/2024. Despite the resident's dependency on mobility and activities of daily living, and the presence of fall precautions, the care plan was not reviewed quarterly as required. The resident's care plan included the use of bilateral bed bolsters, a floor mattress, a pad alarm in bed, a self-release belt while in a wheelchair, and an abdominal binder for safety. However, the care plan had not been updated since 8/19/2024, and there was no interdisciplinary meeting conducted to review and revise the care plan for the last quarter of 2024. This oversight was confirmed during interviews with the registered nurse and the Minimum Data Set Nurse, who acknowledged the importance of regular reviews to minimize the use of restraints and prevent complications. The facility's policy on physical restraints, last reviewed on 12/3/2024, emphasized that restraints should not be used for discipline or convenience and should be re-evaluated regularly. The Director of Nursing confirmed that the care plan should have been reviewed quarterly to assess the effectiveness of the interventions and goals. The failure to conduct these reviews had the potential for unnecessary use of physical restraints, which could lead to physical and psychosocial decline in the resident.
Plan Of Correction
F657 CFR(s): 483.21(b)(3)(i) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The IDT met on 2/24/25 to review resident 73's use of physical restraints, to review and revise the care plan to reduce the potential for unnecessary use of physical restraint. Evaluated all devices and family notified and wants the devices to continue due to benefits outweighing the risks. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: All residents are potentially affected by the facility practice. 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 MDSN/designee will re-educate the nursing staff and IDT on completing a physical restraint/device assessment quarterly and with significant change; with revision of the care plan immediately following to reduce the potential for unnecessary use of physical restraint that can result in physical and psychosocial decline of the resident. The Director of Staff Development will orient new nursing personnel, at the time of hire and annually, on the facility policy and procedure, "Restraints," including completion of a quarterly restraint/device assessment with revision to the resident's care plan immediately following or as soon as practicable to support the residents' psycho-social well-being. The Director of Nursing/designee will re-educate the licensed nurses and interdisciplinary team on or before 3/21/2025 regarding the facility policy and procedure, "Care Plan," timing and revision with emphasis on completion of revised care plan interventions after each assessment including comprehensive and quarterly assessments or at the time of a significant change. D. How the facility plans to monitor its performance to make sure solutions are sustained: The IDT will monitor completion of quarterly and with significant change assessments, with revision of the care plan immediately following to reduce the potential for unnecessary use of physical restraint that can result in physical and psychosocial decline of the resident. The Director of Staff Development will orient new nursing personnel, at the time of hire and annually, on the facility policy and procedure, "Restraints," including completion of a quarterly restraint/device assessment with revision to the resident's care plan immediately following or as soon as practicable to support the residents' psycho-social well-being. The Director of Nursing/designee will re-educate the licensed nurses and interdisciplinary team on or before 3/21/2025 regarding the facility policy and procedure, "Care Plan," timing and revision with emphasis on completion of revised care plan interventions after each assessment including comprehensive and quarterly assessments or at the time of a significant change. D. How the facility plans to monitor its performance to make sure solutions are sustained: The IDT will monitor completion of the resident's care plan following completion of the resident's quarterly assessments in accordance with the RAI schedule to reduce the potential for the use of unnecessary restraints. The Director of Nursing will report trends identified during the IDT meetings and care plan review 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 F657 F657 F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. 2. MD was notified about the missed doses on 2/28/25 with no new orders. 3. The treatment nurse completed a skin assessment of Residents 69, 29, and 52 to identify signs or symptoms of skin breakdown in the area of routine injections. Residents 69, 29, and 52 did not have any signs or symptoms including discomfort in the area of injection sites. 4. Licensed Nurses are rotating injection sites for Resident 69, 29, and 52 and all residents who receive routine injections. 5. Licensed nurses are administering levothyroxine to Resident 197 in accordance with the physician order for administration. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: