Failure to Timely Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise comprehensive care plans by the required target dates for four residents. According to the facility's own Care Plan Policy, care plans are to be periodically reviewed and revised to ensure they reflect the current necessary care and services. However, for four residents with various diagnoses including COPD, hypertension, hyperlipidemia, hypothyroidism, type II diabetes, and heart failure, their care plans were not updated by the specified target dates. For example, one resident with a catheter had a care plan with a target date that was missed, and other residents had all their care plans overdue for revision. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plans for these residents were beyond their target dates and should have been updated accordingly. The failure to update care plans as required was identified through review of facility policy, clinical records, and staff interviews.
Plan Of Correction
Director of Nursing or Designee will provide education to the Interdisciplinary Team on the requirements of developing a comprehensive person-centered care plan within 7 days after completion of the comprehensive assessment and then ongoing review/revise after each assessment including comprehensive and quarterly reviews by 08/30/2025. Residents R4, R11, R78, and R84 had completed care plan reviews. All other residents, triggering with late review dates, will be reviewed and updated by 09/15/2025. 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 care plans have been reviewed/revised within the target date. All findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.