Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral and Medical Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in significant deficiencies. For one resident with a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, new wandering and exit-seeking behaviors were documented for at least a week prior to an incident where the resident eloped from the facility unnoticed and was outside unsupervised for approximately fifteen minutes. Despite staff observations and documentation of these behaviors, including packing belongings and attempting to leave, the care plan was not updated to address elopement or wandering risk. Progress notes indicated that interventions such as one-on-one observation and the application of a wander management device were initiated only after the elopement occurred, but these were not reflected in the resident's care plan. Multiple staff interviews confirmed that the care plan was not updated in response to the resident's behavioral changes, and the interdisciplinary team did not coordinate to ensure the care plan addressed the new risks. Another resident was admitted with a nephrostomy tube for urinary drainage due to obstructive uropathy. The hospital discharge summary and admission nursing assessment noted the presence of the nephrostomy tube, but the initial and comprehensive care plans did not include any focus, goals, or interventions related to nephrostomy tube care. There were no instructions for site care, flushing, dressing changes, or infection prevention, and the facility did not contact the physician or specialist for guidance on nephrostomy care upon admission. Staff interviews revealed that nursing staff relied on general practice rather than formal guidance, and the MDS Coordinator acknowledged that the absence of a care plan for the nephrostomy tube was an oversight. The DON and Medical Director both confirmed that the lack of a care plan for this specialized medical device was a failure in the care planning process and could result in missed or inconsistent care. The facility's policies required that care plans be person-centered, updated upon changes in condition, and include measurable goals and staff approaches for each identified problem or need. However, in both cases, the facility did not follow its own policies or regulatory requirements to ensure that care plans were comprehensive and updated in response to significant changes in residents' conditions or care needs. This failure led to a lack of clear instructions for staff and placed residents at risk for inadequate supervision and care.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident# 1. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clincial Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.