Deficiencies in Comprehensive Care Plan Development
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, diagnosed with atrial fibrillation and heart failure, the care plan did not include any planning for the use of anticoagulant medication or monitoring for side effects, despite a physician's order for Apixaban. This oversight was identified during a review of the resident's clinical record and confirmed in an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the expectation for accurate care plan development. Another resident, diagnosed with dementia and chronic obstructive pulmonary disease, had no information related to her cognitive impairment or dementia diagnosis included in her care plan. This resident had been admitted to the facility after multiple emergency room visits due to confusion, with a significant cognitive impairment noted in her MOCA score. The absence of this critical information in her care plan was confirmed during an interview with the Nursing Home Administrator, who stated that the cognitive impairment/dementia diagnosis should have been included.
Plan Of Correction
1. The Care plans identified for dementia (R24) and anticoagulation (R13) were updated upon discovery. 2. No other care plans were identified as not including a diagnosis or medication. Education was provided by the Regional Nurse/designee to the IDT team on ensuring Care plan accuracy with medications and diagnosis to their respective discipline. 3. An audit will be conducted by the RNAC or designee on care plans on 5 patients per week x 2 weeks then 5 patients monthly x 2 months for patients with a dementia diagnosis or on anticoagulation treatment. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.