Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the care plan was not updated to reflect the resolution of a skin condition, and there were no interventions in place to prevent the development of new skin issues. The resident had a history of immobility and skin conditions, but the care plan did not include necessary updates or preventive measures. The MDS Coordinator acknowledged the oversight and stated that care plans should be updated within a couple of days when new issues arise. For another resident, the facility did not have a care plan in place for medications prescribed for agitation and restlessness. The resident had multiple medication orders, but there were no interventions documented to monitor for behaviors or side effects. The MDS Coordinator confirmed that a care plan should have been in place for the medications, including monitoring for potential side effects. This lack of a comprehensive care plan for medication management was identified as a deficiency during the survey.
Plan Of Correction
Resident #37 care plan updated for maintenance and prevention and Resident #59 care plan developed and implemented for medications. 100% audit of residents with medications and for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for medications. DON or designee to audit residents on medications and for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly.