Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents were reviewed and revised to reflect their current status. For one resident, diagnosed with dementia, anxiety disorder, and depression, the clinical record indicated the presence of edema in both lower legs and a physician's order for TED stockings. However, the resident's care plan did not include a focus on the edema or the use of TED hose, which was confirmed by the Director of Nursing during an interview. Another resident, diagnosed with congestive heart failure and cognitive function issues, had a care plan that included a focus area on smoking, despite the facility's non-smoking policy. The care plan mentioned a smoking evaluation and orientation to smoking areas, although the resident was not an active smoker. This discrepancy was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged that the smoking focus should have been removed from the care plan.
Plan Of Correction
1. The identified care plan was updated to reflect that patient R55 was not an active smoker and this was resolved. R 48 care plan was updated to include the use of Ted hose to control edema. 2. No other care plans were identified as needing updated secondary to a change in plan of care. 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 for 5 patients per week x 2 weeks then 5 patients monthly x 2 months on patient care plans. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.