Deficiencies in Timely and Complete Care Planning
Penalty
Summary
The facility failed to ensure timely development of person-centered care plans for residents, as evidenced by deficiencies identified during a recertification survey. Resident #272 was readmitted with a Peripherally Inserted Central Catheter (PICC) line, but a care plan for its use and care was not developed until seven days after admission. This delay occurred despite the facility's policy requiring care plans to be initiated within 48 hours for residents with a PICC line. The Registered Nurse responsible for the admission assessment acknowledged the oversight, and the Director of Nursing Services confirmed the expectation for timely care plan initiation. Resident #3's care plans for Activities of Daily Living (ADLs) were incomplete, lacking goals and interventions. The resident required maximum assistance for dressing and was dependent on staff for transfers. Despite a quarterly care plan meeting, the interdisciplinary team failed to identify and address the incomplete care plans. The Minimum Data Set Coordinator and the Director of Social Work both acknowledged the oversight, with the latter stating that the care plans should have been reviewed and completed during the quarterly meeting. Resident #19, who had severe cognitive impairment and received oxygen therapy, had a care plan for noncompliance that was incomplete, lacking goals and interventions. The resident was observed not receiving oxygen therapy as prescribed. The Director of Social Work, responsible for initiating the care plan, admitted to the error of not including necessary goals and interventions. The Director of Nursing Services confirmed that the care plan should have been complete, indicating a lapse in the facility's adherence to its policy on comprehensive care planning.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 A. Immediate Corrective Action: 1. Resident #272 who still resides in facility was affected by this deficient practice. 2. The CCP for resident #272 titled PICC/Central Line Care/Management of CVP Line was initiated on 1/24/25 to ensure the proper management of the PICC line. 3. RN #2 was counseled and re-educated regarding the initiation of resident centered plan of care. 4. Resident #3 who still resides in the facility was affected by this deficient practice. 5. The CCP for resident #3 was modified on 1/24/25 to reflect resident centered goals and interventions. 6. The Director of Social Work was counseled and re-educated to ensure resident centered goals and interventions are reflected on care plans and reviewed quarterly. 7. Resident #19 who still resides in the facility was affected by this deficient practice. 8. The CCP for resident #19 was modified on 1/24/25 to reflect resident centered goals and interventions. 9. The Director of Social Work was counseled and re-educated to ensure that the resident centered goals and interventions are reflected when the care plan is initiated. B. Identification of Others: 1. All residents that reside in the facility have been identified at risk for failure to develop and implement a comprehensive care plan. 2. The facility initiated an audit of all residents’ comprehensive care plans to ensure development and implementation. The residents discovered to be at risk of failure to develop and implement a comprehensive resident centered comprehensive care plans were identified and modified immediately. C. Systematic Review to Prevent Re-Occurrence: 1. The Interdisciplinary Care Plan Team reviewed the Care Plan Policy and Procedure and no changes were necessary. 2. All clinical staff responsible for care planning have been re-educated by the RN Educator to ensure development and implementation of a comprehensive care plan for all residents. 3. The DNS developed an audit tool to be utilized at initial, quarterly and annual care plan meetings to ensure that care plans are reviewed. 4. The DNS developed an audit tool to ensure development and implementation of all residents. Ten residents’ comprehensive care plans will be audited weekly for three months then quarterly thereafter for one year. D. Quality Assurance: 1. The DNS/Designee will report on the findings of the audit quarterly at the QAPI meeting. 2. Negative findings will be immediately addressed by the DNS/Designee with onsite teaching/in-service, and disciplinary action as necessary. 3. The DNS/Designee is responsible to ensure correction of this deficient practice.