Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for four residents, as required by federal regulations. For one resident with end stage renal disease, Type 1 diabetes mellitus, and a history of myocardial infarction, there was no care plan addressing the administration of an anti-psychotropic medication (Olanzapine). The resident was cognitively intact and able to make medical decisions, but the absence of a care plan meant that staff did not have documented goals or interventions related to the use of this medication. The facility's own policy required individualized care plans with measurable objectives and timetables to be developed within seven days of the comprehensive assessment, but this was not followed. Another resident, with a history of hyperlipidemia, dementia, and cerebral infarct, was involved in a resident-to-resident altercation and attempted to elope from the facility. Despite these significant events, there was no care plan created to address the altercation or the risk of elopement. Staff interviews confirmed that the lack of care plans for these incidents placed the resident at risk for recurrence, as interventions to prevent future incidents were not implemented and the care team was not made aware of the resident's history. A third resident, admitted with respiratory failure, a gastrostomy, and dementia, did not have a care plan for dementia upon admission, despite severe cognitive impairment and total dependence for activities of daily living. Staff and the DON acknowledged that a care plan should have been created at admission to guide care. Similarly, another resident with sickle-cell disease, bipolar disorder, and PTSD did not have a care plan addressing PTSD. Staff were unaware of the diagnosis, and both nursing staff and the DON stated that a care plan was necessary to ensure consistent, individualized care and to address the resident's specific psychological needs. The facility's policy required comprehensive, person-centered care plans for all residents, but this was not consistently implemented.
Plan Of Correction
F656: DEVELOP/ IMPLEMENT COMPREHENSIVE CARE PLAN CORRECTIVE ACTIONS Resident 5 was reassessed on 3/13/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. Resident 196 was transferred to an acute hospital on 3/6/25 for evaluation and treatment per MD order. Resident readmitted to the facility, and the comprehensive care plan was updated reflecting the resident's current status. Resident 37 was reassessed on 3/4/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident to resident altercation and the resident's current status. Resident 68 was reassessed on 3/5/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. Resident 47 was reassessed on 3/5/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. OTHER RESIDENTS AFFECTED IDENTIFICATION IDT conducted chart review on 3/25/25 and 3/28 to all active residents, including newly admitted residents, to ensure that the plan of care is current and updated to meet the resident needs. Two other residents were found to have been affected by the deficient practice. The comprehensive care plan was reviewed and updated for the affected residents on 3/28/25. DON and/or designee provided in-service to the RNs and LVNs on 3/21/25 about the importance of initiating care plans timely upon admission and updating the resident's care plan for any change of conditions. MEASURES AND SYSTEMIC CHANGES Resident's clinical records will be reviewed by the IDT within 48 hours of admission to check for care plan completion and if special care issues reported by the endorsing hospital are addressed in the care plan. MDS staff will complete the comprehensive care plan within 7 days of a resident's comprehensive assessment to outline the resident's needs, goals, and interventions to promote their well-being. OTHER RESIDENTS AFFECTED IDENTIFICATION IDT conducted chart review on 3/25/25 and 3/28 to all active residents, including newly admitted residents, to ensure that the plan of care is current and updated to meet the resident needs. Two other residents were found to have been affected by the deficient practice. The comprehensive care plan was reviewed and updated for the affected residents on 3/28/25. DON and/or designee provided in-service to the RNs and LVNs on 3/21/25 about the importance of initiating care plans timely upon admission and updating the resident's care plan for any change of conditions. MEASURES AND SYSTEMIC CHANGES Resident's clinical records will be reviewed by the IDT within 48 hours of admission to check for care plan completion and if special care issues reported by the endorsing hospital are addressed in the care plan. MDS staff will complete the comprehensive care plan within 7 days of a resident's comprehensive assessment to outline the resident's needs, goals, and interventions to promote their well-being. MEASURES AND SYSTEMIC CHANGES (CONTINUED) Licensed nurse will update the resident's plan of care within 24 hours for any resident’s COC and special needs lists. PERFORMANCE MONITORING The IDT will conduct care plan meetings within 7 days after admission to discuss the resident's overall care and level of assistance required, then quarterly and as needed for any unusual occurrence. The DON/designee will review the special needs list for accuracy and completeness weekly and as needed. The DON/designee will monitor the corrective action for continuous compliance. Findings will be reviewed by the Director of Nursing/Designees weekly for the first three months and will be presented to the QA committee monthly for three months for further evaluation and recommendations. 3/28/2025