Failure to Timely Update and Revise Care Plans Following Changes in Resident Condition and Medication
Penalty
Summary
The facility failed to revise and update care plan interventions in a timely manner for multiple residents, as required by state regulations. For one resident, after experiencing a fall while attempting to transfer between wheelchairs, the care plan was not updated to reflect the incident or to address the new safety concerns. The resident, who had a history of vision impairment and mobility issues, reported that the fall occurred due to a malfunctioning wheelchair lock and confusion during the transfer process. Despite documentation of the incident and the resident's injuries, the care plan remained unchanged, and staff interviews revealed uncertainty about who was responsible for updating care plans following such events. Another resident's care plan was not revised to reflect changes in diagnoses and medication orders. The resident had multiple discontinued and current medication orders, including psychotropic drugs, but the care plan did not accurately address the resident's current medication regimen or associated diagnoses. Interviews with nursing and MDS staff confirmed that there was no documented diagnosis for some of the medications administered, and care plans were not consistently updated to reflect medication changes or discontinuations. The facility's policy required that information from ongoing evaluations be incorporated into the comprehensive care plan, but this was not consistently followed. Additionally, the same resident did not have a care plan developed or implemented to address a newly identified condition. Both the Regional MDS Coordinator and the Assistant MDS Coordinator acknowledged the absence of a care plan for this condition during interviews. The lack of timely and accurate updates to care plans, as well as the failure to develop care plans for new diagnoses, constituted noncompliance with regulatory requirements for comprehensive, person-centered care planning.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with alleged deficiencies herein. To remain compliant with all federal and state regulations, the facility has taken actions set forth in the plan of correction. The plan of correction constitutes the facility's allegation of compliance such as the deficiencies cited have been corrected by the date certain. On the DON updated the care plan and added the appropriate intervention for resident #92. On the regional reimbursement coordinator revised and updated the care plans for the changes of diagnosis and medications for resident #76. On the regional reimbursement coordinator initiated the care plan for resident #76. On [date], the Regional Nurse Consultant conducted a quality review of residents who have had a [specific event or condition] in the past 30 days to ensure that interventions are added to the care plan timely. Follow up based on findings. On [date], the Regional Reimbursement Coordinator conducted a quality review of residents with new active diagnosis or medication changes in the past two weeks to ensure that care plans were appropriately developed or updated. Follow up based on findings. On [date], the Regional Nurse Consultant conducted a quality review of current residents with the diagnosis of [diagnosis] to ensure that appropriate care plans have been developed. No additional findings noted. By [date], the licensed nurses including the MDS nurses were educated by the Staff Development Coordinator on the components of N071 with an emphasis on accurate revisions and updating of care plans. As a systematic change, newly hired licensed nurses, including MDS nurses, will be educated on the components of N071 with an emphasis on accurate revisions and updating of care plans. The DON/designee will conduct quality monitoring audits of 10 random residents weekly for 4 weeks, then 10 random residents monthly for 2 months to ensure proper revision and updating of the care plans. The findings of these quality monitoring audits are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.