Failure to Revise and Timely Complete Comprehensive Care Plans
Penalty
Summary
The facility failed to revise and complete comprehensive care plans for four residents as required. For two residents with cognitive impairment and significant medical conditions, the care plans did not include the use and monitoring of seat belts and alarms as restrictive devices. Specifically, one resident with hemiplegia, hemiparesis, and vascular dementia had a physician order for a Velcro seat belt for positioning and safety, but the care plan only referenced the seat belt as a fall intervention and did not address monitoring or assessment of the device as necessary, appropriate, or least restrictive. Another resident with dementia and multiple comorbidities had orders for an alarming Velcro seat belt and a pressure alarm, but the care plan did not address these devices or include any plan for monitoring or assessment. Observations and interviews confirmed the devices were either in use without proper care plan documentation or had been removed without documentation or care plan revision. Additionally, the facility failed to complete comprehensive care plans within the required timeframe for two other residents. For both, the care area assessment and care plan were completed after the 21-day post-admission requirement. Interviews with the MDS Coordinator confirmed the late completion of these care plans. Record reviews, staff interviews, and facility policy review all supported these findings. The facility's policy indicated that care plans should be used in developing daily care routines and be available to staff responsible for resident care, but this was not consistently followed for the residents reviewed.
Plan Of Correction
Resident #3 and #25 were immediately assessed and found to have no adverse effects. All residents with restrictive devices and alarms have the ability to be affected. Seatbelt for resident #25 was DCed immediately by DON on 5/21/25. Seatbelt for resident #3 was requested to stay in place by resident. Chart was reviewed by DON immediately on 5/21/25 to insure proper documentation was in place. Resident #3 and #25 comprehensive care plan immediately reviewed and updated by MDS on 5/21/25. Admin immediately provided MDS Coordinator education on comprehensive care plan policy and timely submission. Education on appropriate alarm and restrictive device usage and documentation provided by DON to all staff on 5/22/25. All residents alarms/restrictive devices were reviewed by IDT on 5/28/25 to ensure appropriateness and supporting documentation in place. Weekly audits of three alarms/restrictive devices to be complete by DON/designee to ensure the care plan is accurate and the device in place is appropriate as the least restrictive option with proper monitoring for 4 weeks. Results to be reviewed in QAPI.