Failure to Develop and Implement Care Plan for Hypertensive Heart Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with hypertensive heart disease without heart failure. Although the resident was admitted with this diagnosis and had a physician's order to monitor for orthostatic hypotension by checking blood pressure once a week, the care plan did not address hypertensive heart disease or include the required blood pressure monitoring. Instead, the care plan only referenced coronary artery disease related to atrial fibrillation, which was not supported by the resident's Minimum Data Set or medical records. Record reviews showed that the resident's Minimum Data Set listed active diagnoses of hypertension and depression, and the physician order summary specifically required monitoring for orthostatic hypotension. The Director of Nursing confirmed that the care plan was not updated to reflect the physician's order for blood pressure monitoring. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and services to meet residents' needs, but this was not followed for the resident in question.
Plan Of Correction
F 656 Develop/ Implement Comprehensive Care plan Corrective Action: Resident was discharged on 04/03/2025. Corrective Action Continued: DON initiated in-services to licensed nurses on 05/02/2025 regarding the importance of developing accurate care plans based on diagnosis and ensuring they reflect the related interventions. Other Residents Affected Identification: All residents have the potential to be affected by the deficient practice. On 05/02/25, all residents with a diagnosis of Hypertension were audited by DON/Designee to ensure a care plan is present and reflects current interventions that might include Blood Pressure Monitoring. No other residents were affected by the deficient practice. Measures and Systemic Changes: DON provided an in-service to MDS nurse on 05/02/25 to ensure care plans reflect residents' diagnoses with their corresponding interventions. Care plans will be reviewed by the MDS nurse upon admission and quarterly at minimum thereafter for accuracy. The DON initiated an in-service to Licensed Nurses on 05/02/25 regarding quality of care, with an emphasis on the importance of monitoring BP and updating care plans based on physician's orders. Monitoring Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved. Date: 05/07/25