Failure to Develop Comprehensive Care Plans After Resident Altercation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents following an incident in which one resident, who was confused, accidentally grazed another resident's right cheek while being moved by staff. The care plans did not reflect the individual care needs of either resident in relation to this incident, as required by federal regulations. Specifically, there was no care plan initiated on the day of the incident to address the event for either resident. Medical record reviews showed that both residents were competent and able to make decisions at the time of the incident. One resident had a BIMS score indicating cognitive intactness, and both had recent admissions or readmissions to the facility. Despite the incident being documented in the change in condition notes, the care plans for both residents did not include any problems or interventions related to the altercation. During an interview and concurrent medical record review with the DON, it was confirmed that the care plan problems related to the incident were missed for both residents. The DON acknowledged that the care plan for one resident was only completed after the surveyor's inquiry, which was not timely in relation to the date of the incident.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the same deficient practice: On 6/13/25, the IDT (Interdisciplinary Team), including the Administrator, DON, MDS Coordinator, Social Services, and Dietary Manager, reviewed and updated the care plan of the identified resident to ensure it was comprehensive, addressing all assessed needs, goals, and interventions, including psychosocial, medical, and functional needs. The resident and responsible party were included in the care plan discussion, and documentation was completed in the medical record. On 6/13/25, the DON and MDS Coordinator reviewed other residents' active care plans for gaps or incomplete documentation. No other residents were found to have been affected by incomplete or non-comprehensive care plans. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: A facility-wide audit of all current residents' care plans was initiated on 6/13/2025 by the Medical Records Director, MDS Coordinator, and reviewed by the DON to ensure all plans reflected residents' current status, needs, goals, and preferences. Any identified discrepancies were corrected immediately, with the care plan updated, and responsible parties notified as appropriate. No additional concerns were identified. What measures will be put in place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 6/13/25, 6/26/25, 7/1/25, and 7/2/25, an in-service training was conducted by the DON for licensed nurses and IDT members on the requirements for developing and implementing a comprehensive care plan per federal and state regulations. Training emphasized: - Care plans must address identified needs from resident assessments. - Care plans must include measurable goals, specific interventions, and timelines. - Involvement of residents and/or responsible parties in care-plan development. - Timely updates to care plans when changes in condition occur. The MDS Coordinator will conduct care plan audits to ensure completeness, resident-specific interventions, and timely updates. The IDT will conduct care plan reviews in weekly clinical meetings and quarterly care plan meetings with resident/family participation. How the facility will monitor its performance to ensure solutions are sustained: The DON and MDS Coordinator will conduct random audits of 5 resident care plans weekly for June to September 2025 to ensure compliance with comprehensive care plan requirements. Findings will be presented at the monthly QA meetings for review, trend monitoring, and corrective action planning if needed. Audits will continue quarterly thereafter to ensure ongoing compliance. The Administrator and DON will provide oversight to ensure care plans remain current, complete, and compliant with regulations.