Failure to Develop Comprehensive Care Plans for PTSD and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by federal regulations. For one resident with a diagnosis of Parkinson's disease, PTSD, anxiety, and depression, the clinical record review showed that there was no care plan addressing PTSD. This omission was confirmed by the Nursing Home Administrator during an interview. For another resident with chronic obstructive pulmonary disease, hypertension, and heart failure, the review of the clinical record revealed that there was no care plan for respiratory care involving the use of oxygen, which was also confirmed by the Director of Nursing. The facility's own policy requires the development of comprehensive care plans that include measurable objectives and timetables to address each resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment. The care plans are to be developed by the interdisciplinary team and periodically reviewed and revised. In these two cases, the required care plans for PTSD and for respiratory care with oxygen were not developed, despite the residents' documented needs and diagnoses.
Plan Of Correction
Director of Nursing or Designee will provide education to the Interdisciplinary Team on the requirements of developing and implementing a comprehensive person-centered care plan for each resident reflecting their specific needs by 08/30/2025. R8's care plan was updated to reflect that he has PTSD, goals and interventions specific to him. R84's care plan was updated to reflect her respiratory plan of care. An audit of all current residents with an order for oxygen will be conducted to ensure that they have a respiratory care plan. An audit of all current residents with a diagnosis of PTSD will be reviewed to ensure that they have a person-centered care plan completed. Ongoing compliance will be maintained by the Director of Nursing or designee checking 10% of current residents' care plans weekly for one month and then 5% weekly for one month to ensure that the care plans are person-centered for each resident, including measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Findings of these audits will be reviewed in monthly Quality Assurance and Performance Improvement meetings.