Failure to Update Care Plan After Resident Incidents
Penalty
Summary
The facility failed to update the care plan with appropriate interventions for a resident who experienced multiple incidents while at the facility. Despite the resident being sent to the hospital on several occasions with significant changes in condition and new diagnoses, the care plan was not revised to address these events. Medical record reviews and staff interviews confirmed that the care plan did not reflect updated interventions after each incident, even though the resident returned from the hospital with new or ongoing medical issues. Staff interviews revealed that there was an expectation for care plans to be updated after incidents or significant changes in a resident's condition. However, the responsible staff either believed the existing interventions were sufficient or were unaware that updates had not been made. Documentation showed that the care plan remained unchanged after the resident's hospitalizations and subsequent returns, despite clear evidence of changes in the resident's health status. The facility's own policy required care plans to be reviewed and updated as changes in the resident occurred, including changes in diagnosis or condition. The failure to update the care plan as required by both facility policy and federal regulations resulted in a deficiency, as the care plan did not accurately reflect the resident's current needs or provide guidance for staff following significant health events.
Plan Of Correction
F 000 F657 Care Plan Timing and Revision ELEMENT ONE: CORRECTIVE ACTION: The care plan of Resident #6 was reviewed and updated to reflect history and potential risk of NJ Exec Order 26.4b1 [R]. The staff caring for Resident #6 were educated on the updates to the care plan. The Director of Nursing / designee re-educated the nursing administrative team and U.S. FOIA (b) (6) on the resident care plan policy. An audit of the care plans of residents with history and/or potential risk of NU EXOD or NJ Ex Order 26.4(b)(1) [R] was conducted and care plans updated as needed. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Residents with incidents of illicit drug abuse and/or overdose will be discussed and care plans updated at weekday clinical meetings. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Illicit drug abuse and/or overdose are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of care plans at the weekday clinical meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meeting for 3 months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025
Removal Plan
- Resident #6's care plan was updated.
- Administrative nursing staff and social workers were educated on updating and implementing care plans when incidents occur.
- A process was implemented to occur during daily morning clinical meetings to ensure that care plans are updated when incidents occur.