Failure to Develop Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans to address dementia and cognitive loss for three residents who had been admitted with a diagnosis of dementia. Clinical record reviews for these residents showed that, although the facility assessed each resident as having dementia and determined that a care plan would be developed, there was no evidence in the care plans that such individualized plans addressing dementia and cognitive loss were actually created or implemented. This lack of documentation was confirmed by both the Nursing Home Administrator and the Director of Nursing during interviews, who acknowledged that no further documentation existed to show that appropriate care plans had been developed prior to surveyor inquiry. For one resident, the care plan was only developed after the surveyor raised concerns, and it was noted that the plan should have included family involvement in its development. The findings were confirmed through interviews with facility staff, including a social worker, who acknowledged that the individualized dementia care plan was created only after the issue was brought to their attention by the surveyor. The deficiency centers on the facility's failure to provide appropriate, individualized treatment and services for residents with dementia as required.
Plan Of Correction
Newly completed individualized dementia care plans were developed for residents #33, #52, and #61 by the facility's social worker. No evidence of any actual ill effect exists on any of the residents in our community due to the lack of adherence to the requirements of said individualized care plans. A review of the residents admitted within the past six (6) months was conducted to ensure all residents with a current diagnosis of dementia have individualized care plans in place. Future admissions or residents with newly diagnosed dementia will have a new care plan completed within 72 hours. An education session was completed by the director of nursing or designee with social services on the importance of accuracy of diagnosis on care plans and ensuring that they are individualized to each resident. Audits will be completed on five (5) charts weekly for one month and biweekly for three (3) months relating to the residents with a diagnosis of dementia and ensure the care plan has been appropriately annotated. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.