Failure to Develop Comprehensive Care Plan for Palliative Care
Penalty
Summary
The facility failed to ensure the development and implementation of a comprehensive person-centered care plan for a resident, specifically addressing comfort and palliative care needs. This deficiency was identified during a recertification survey, where it was found that a resident with severe cognitive impairment and total dependence on staff for daily activities did not have a care plan for comfort/palliative care, despite being on such care as per a nurse practitioner's notes. The resident was observed to be alert but non-responsive, with intravenous and oxygen support in place. Interviews with facility staff revealed a lack of clarity regarding responsibility for developing the care plan. A registered nurse indicated that it was the social worker's responsibility to create the care plan, while the Director of Social Services was unaware of this requirement, believing their role was complete after documentation. This miscommunication and lack of awareness led to the absence of a documented care plan for the resident's comfort/palliative care, violating the facility's policy and regulatory requirements.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Action a. Resident 95 comprehensive care plan updated to reflect comfort care. II. Identification a. Audit of all residents with advanced directives done immediately on 3/5/25 to ensure appropriate care plans were in place. No negative findings. III. Systemic Changes a. Administrator and DON reviewed Comprehensive Care Plan Policy on 3/5/25 and found it to be compliant. b. Administrator in-serviced Social Work Director and Social Worker on responsibility of implementing care plans for comfort care measures. IV. Monitoring a. DON developed an audit tool to ensure all residents on comfort care have appropriate care plans. Any resident with Advanced Directives triggering comfort care measures will be sampled for audit. b. Audit will be conducted monthly x 12 months. c. Audits with negative findings will have immediate corrective action and reported to the Administrator for review and follow up. d. Audit findings will be presented to the QA committee quarterly by the Director of Nursing / designee. V. Responsibility a. The Director of Nursing will be responsible to ensure correction of this deficiency.