Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which is a requirement under Federal and State regulations. Resident #27, who was on palliative care and receiving pain medications, did not have a care plan addressing pain management and palliative care. Observations noted that the resident expressed experiencing pain, and physician orders included Tylenol and a topical gel for pain management. Despite these needs, there was no documented evidence of a care plan for pain management or palliative care in the resident's records. Similarly, Resident #123, who had a diagnosis of diabetes mellitus, did not have a care plan addressing their diabetic condition. The resident required maximal assistance with daily activities and had physician orders for insulin administration. However, a review of the resident's comprehensive care plans showed no documentation of a care plan for diabetes management. Interviews with nursing staff revealed that it was the responsibility of nurse supervisors and registered nurses to initiate and update care plans, but this was not done for these residents.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME) F656 I. Immediate Corrective Action: Resident # 27 1) On 3/31/25 the IDT Team developed a CCP for Palliative care and pain management. 2) On 4/2/2025 the resident was reassessed by Nurse Practitioner and the total plan of care including pain management and palliative care was reviewed. 3) On 4/17/2025 the SW and RNS met with the resident’s family to review the current plan of care for pain management and palliative care and the resident’s family verbalized satisfaction with the plan. 4) On 4/1/2025 the DON provided the SW responsible for initiating the palliative care CCP with education and counseling. Resident # 123 1) On 3/28/2025 the IDT Team developed a CCP for Diabetes. 2) On 3/28/25 the resident was reassessed by Nurse Practitioner and the total plan of care including diabetic management was reviewed. 3) On 3/31/2025 the DON issued an educational counseling to the Admitting RN for not initiating the diabetic management CCP. II. Identification of Others: 1) The facility respectfully states that all residents could potentially be affected. 2) A report will be generated from the EMR- Sigma care to determine which residents have orders for Palliative care. This list will be utilized by the SW in conjunction with the RNS to ensure all residents with palliative care have an individualized care plan. Any issues will be immediately corrected. 3) A report will be generated from the EMR-Sigma care to determine which residents have pain management medication orders. This list will be utilized by the RNS to ensure all residents have an individualized pain management care plan. Any issues will be immediately corrected. 4) A report will be generated from the EMR-Sigma care for all residents with diabetes. This list will be utilized by the RNS to ensure all residents with diabetes have an individualized care plan. Any issues will be immediately corrected. III. Systemic Changes: 1) The DNS and members of the IDT reviewed the P/P on Comprehensive Care Planning and found same to be compliant. 2) All RNs, MDS Coordinators, and IDT Team members will be inserviced by the In-service Coordinator. Highlights of the lesson plan include: - The responsibility to develop and implement a care plan that describes all of the following with emphasis on palliative care, pain management and diabetes; a. Resident goals and desired outcomes; b. The care/services that will be furnished so that the resident can attain or maintain his/her highest practicable physical, mental, and psychosocial well-being; c. Resident's medical, nursing, physical, mental, and psychosocial needs, and preferences, and how the facility will assist in meeting these needs and preferences. - The specific CCP’s that each member of the IDT is responsible for initiating. - The responsibility of all members of the IDT to initiate or update CCP’s for changes in the residents’ care plan that are addressed at the morning QA Meeting. - The responsibility of the IDT to review each resident’s physician orders [REDACTED]. IV. Quality Assurance: 1) The DON developed an audit tool to ensure that all care plans are developed, implemented, and reviewed, including goals and interventions after each care plan meeting. 2) The DON/Designee will review 8 randomly selected residents weekly x 4 weeks followed by 8 residents each month including new admission x 6 months. 3) Any findings regarding CCP implementation will be reviewed at the monthly QA meeting for follow-up. 4) Findings will be reported quarterly to QA Committee to track compliance and monitor sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Director of Nursing