Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for three residents during a recertification survey. Resident #28, who had diagnoses including hypertension and was prescribed a diuretic, did not have a comprehensive care plan addressing the use of the diuretic. The cardiac care plan initiated for this resident lacked focus, goals, and interventions. Registered Nurse #3 confirmed the absence of a comprehensive care plan for the diuretic medication. Resident #79, who was receiving medical treatment three times a week, had a care plan initiated but it lacked necessary interventions, rendering it incomplete. Registered Nurse #4 acknowledged the missing interventions in the care plan. Resident #93, who was severely cognitively impaired and receiving hospice care, did not have a comprehensive care plan related to hospice services. Registered Nurse #4 stated that hospice care plans were not developed at the facility, and communication was maintained through progress notes instead. The Director of Nursing confirmed that comprehensive care plans should be developed for hospice care and that care plans lacking goals or interventions were not considered complete. The facility's policy required an interdisciplinary team to develop individualized care plans to maximize residents' functional potential and quality of life.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Correction: 1) Resident #28 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for the use of diuretics. 2) Resident #79 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for [MEDICAL TREATMENT] care. 3) Resident #93 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for hospice care. 4) The RN Supervisor #3 who was responsible for initiating comprehensive care plans for resident #28 was counseled and educated regarding the policy on Comprehensive Care Planning on (MONTH) 19, 2025. 5) The RN Supervisor #4 who was responsible for initiating comprehensive care plans for resident #79 and #93 was counseled and educated regarding the policy on Comprehensive Care Planning on (MONTH) 19, 2025. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that for all active diagnosis, service, plan of care and medications, a complete comprehensive care plan is initiated upon admission/readmission or change in status and initiated and updated as needed. An audit was completed by the DNS on all outstanding comprehensive care plans on all residents on our current census to ensure that all diagnosis, services, plan of care and medications have an active complete comprehensive care plan including goals. Any identified issues will be addressed (4/25/25). III. Systemic Changes: The Policy and Procedure for Comprehensive Care Plan was reviewed by the DNS and Administrator and found to be in compliance. On 3/31/2025 all licensed nurses received in-service/education on initiating and updating comprehensive care plans upon admission/re-admission or change in status on all active diagnosis, service, plan of care and medications, a complete comprehensive care plan is initiated upon admission/readmission or change in status is initiated and updated as needed. All new and re admissions will be reviewed within 24 hours of admission. All charts will be reviewed by IDT to ensure that a comprehensive care plans were developed for each residents diagnosis, services, plan of care and medications. All in house residents charts will be reviewed by IDT prior to quarterly, annual and significant change care plan meetings to ensure compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have a complete comprehensive care plan with a focus, goal and interventions initiated that will address all active diagnosis, service, plan of care and medications. The DNS will conduct an audit weekly x3 months. Any identified issues related to a delay in care planning results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date: 4/25/25