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 10, who was diagnosed with emphysema and dyspnea, was prescribed oxygen therapy at 2 Liters/Min via nasal cannula. However, there was no care plan developed for this oxygen therapy, as confirmed by a registered nurse. Resident 73, admitted with a risk for elopement, had a physician's order for a safety device (wander guard) on the left ankle, but there was no care plan addressing the use of this device or the resident's elopement risk, as confirmed by the Director of Nursing. Resident 82, who was not cognitively intact and had multiple diagnoses including dementia, heart failure, and diabetes, also had a Stage III pressure ulcer. Despite the facility's policy requiring a turning and repositioning program for residents at risk of pressure injuries, there was no care plan in place for Resident 82's repositioning needs. The Rehab Director confirmed that the resident needed prompting to reposition, yet the care plan did not reflect this requirement. The Director of Nursing confirmed the absence of a care plan for turning and positioning for this resident.
Plan Of Correction
A - Resident R10 had a comprehensive care plan added for oxygen use. Resident R73 had a comprehensive care plan added for safety and elopement. Resident R82 had a comprehensive care plan added for repositioning. B - All residents requiring oxygen, at risk for elopement, and requiring a repositioning program audited to ensure comprehensive care plan in place for oxygen use, elopement risk, and repositioning program. C - Staff educated on completion of comprehensive care plans for oxygen use, elopement risk, and repositioning programs. D - Weekly x 4 then monthly x 2 audits by DON or designee of comprehensive care plans for new resident needs for oxygen use, elopement risk, and repositioning programs. Results discussed during QAPI meetings.