Failure to Develop and Implement Care Plans for IV and Ostomy Care
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive care plans for two residents who required specialized care. One resident was admitted with a colostomy and was receiving daily colostomy care, but there was no corresponding care plan documented in the medical record. Another resident was admitted with an intravenous (IV) line for medication administration to prevent wound infection, yet there was also no care plan addressing IV care in the medical record. Interviews with both residents confirmed the ongoing need for these specialized services, and an interview with the Director of Nursing verified that care plans for colostomy and IV care were not in place for these residents. The absence of these care plans was found during a review of clinical records and staff interviews, constituting a failure to meet federal and state requirements for comprehensive, person-centered care planning.
Plan Of Correction
Immediate Corrective Action: R7 care plan was reviewed and updated accordingly. R8 has been discharged from the facility. Housewide Corrective Action: Current residents with colostomy care and IV care were audited to ensure care plans were present. Policy/ Education: Licensed nurses will be re-educated on the facility's comprehensive care plan policy and ensuring specific care needs (IV and/or colostomy) are added to the care plan as applicable. Performance Monitoring: DON or designee will complete weekly audits x 4 weeks to ensure residents with colostomy care and IV care needs have care plans to reflect specific the same. Results will be reviewed during facility's monthly QAPI meeting. QA meeting will determine the need for continued auditing.