Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. Resident 32 was observed receiving oxygen therapy at 4 liters per minute via nasal cannula, as per a physician's order from June 2024. However, the resident's active care plan did not include any interventions or plans for this oxygen therapy. This was confirmed by the Nursing Home Administrator during an interview. Resident 37, diagnosed with End Stage Renal Failure, undergoes hemodialysis three times a week and has a dialysis shunt in the left upper arm. Despite these significant medical needs, there was no comprehensive care plan addressing the dialysis or the presence of the shunt. This oversight was confirmed by the Director of Nursing. Additionally, Resident 91 experienced significant weight loss, as noted in the quarterly MDS and a weight change note, yet there was no care plan to address this nutritional issue, which was also confirmed by the Director of Nursing.
Plan Of Correction
1. Resident 32 care plan was updated to include oxygen therapy; Resident 37 care plan was updated to include dialysis and the presence of dialysis shunt; Resident 91 care plan was updated to include resident's weight loss. 2. Facility performed house audit to ensure care plans were accurate. Current residents and new admit residents are at risk for not having a comprehensive care plan. 3. NHA, or designee, will educate department leaders and DON, or designee, will educate licensed staff on policy for developing comprehensive care plans for residents. 4. NHA, DON, or designee, will perform random audits of current and new admit residents to ensure comprehensive care plans are done, weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.