Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #37 was admitted with diagnoses including Type 2 diabetes and unspecified abnormalities of gait and mobility. The care plan for this resident 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 MDS Coordinator acknowledged that the care plan should have been updated and resolved earlier. Resident #59, who was admitted with degenerative nervous system issues and restlessness, had no care plan in place for medications prescribed for agitation and restlessness. The MDS Coordinator confirmed that there should have been a care plan to monitor for behaviors and side effects related to these medications. The lack of a care plan for medication management was acknowledged as a deficiency by the MDS Coordinator. Interviews with the MDS Coordinator revealed that care plans should be updated within a couple of days when new issues arise, and that there should be interventions in place for residents with a history of skin issues. The failure to update and implement comprehensive care plans for these residents indicates a lapse in the facility's adherence to regulatory requirements for person-centered care planning.
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.