Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, as required by federal regulations. For one resident with a history of paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure, the care plan did not adequately address the use of Apixaban, an anticoagulant. The Quality Assurance Nurse confirmed that the care plan lacked information on monitoring for side effects, such as bleeding, which is essential for residents on blood thinners. Two other residents, both with histories of urinary retention and neurological or muscular conditions, were identified as candidates for bowel and bladder retraining based on their assessments. Despite documented frequent incontinence and assessment scores indicating suitability for retraining programs, there were no care plans initiated or updated to address bowel incontinence or retraining for these residents. The Registered Nurse Supervisor acknowledged that the absence of these care plans could delay necessary treatment and that all concerns should be reflected in the care plan. Another resident with diabetes mellitus and dementia experienced a significant hypoglycemic event, as documented in the nurse's progress notes. Despite this event, there was no care plan developed to address hypoglycemia. The Director of Nursing confirmed that care plans should be specific and interventions should be implemented and reevaluated, especially following significant events. The facility's own policy required comprehensive, person-centered care plans to be developed and implemented for each resident, but this was not followed in these cases.
Plan Of Correction
F656 - Develop/Implement Comprehensive Care Plan • How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Quality Assurance Nurse (QAN) added the monitoring of the side effect for Apixaban, which included monitoring bleeding for Resident 45. (Exhibit #5) - On 5/29/25, the Registered Nurse Supervisor 1 (RNS1) added bowel incontinence and bowel and bladder retraining in the care plan for Resident 10 and Resident 44. (Exhibit #6) - On 5/30/25, the Director of Nursing (DON) included hypoglycemia monitoring in the care plan for Resident 23. (Exhibit #7) • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/17/25, the Director of Staff Development (DSD) and QAN reviewed the list of residents with anticoagulants, possible candidates for bowel and bladder retraining, and residents at risk for hypoglycemia to ensure care plans were completed accurately. (Exhibit #8) - No other residents were affected by the same deficient practice. • What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Comprehensive Care Plans" dated 12/19/2022. (Exhibit #9) - Starting on 6/17/25, the DON and QAN will conduct a weekly review for three months to ensure care plans were developed and implemented, particularly for anticoagulant medications, hypoglycemia, and bowel and bladder assessment and training programs. (Exhibit #10) - Starting on 6/17/25, the DON will report to the administrator any non-compliance. • How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON will discuss any trends or patterns during the monthly QA committee meetings for three months for review and recommendations and will re-evaluate if any further concerns are identified afterward. Date of completion: June 20, 2025