Repeat Deficiencies and Incomplete Performance Improvement for Catheter Care and Care Planning
Penalty
Summary
The facility failed to demonstrate good faith attempts to correct previously identified quality deficiencies, as evidenced by repeat deficiencies in three areas and incomplete corrective actions outlined in a Performance Improvement Plan (PIP). Document review showed that deficiencies related to notice of bed hold policy, development and implementation of comprehensive care plans, and provision of services meeting professional standards were cited in a previous recertification survey, with correction dates that had passed. Additionally, a PIP addressing compliance with federal regulation F880 was not completed within the targeted timeframe, and action steps to ensure appropriate catheter orders and care plans were not fully implemented. Interviews with the Director of Nursing (DON) and the Administrator confirmed that residents using catheters did not have care plans with appropriate focus, goals, or interventions, and that at least one resident did not have a physician's order for catheter use prior to the survey. The Administrator acknowledged delays in entering necessary orders and care plans, and recognized that the facility lacked routine orders for catheters. The facility's Quality Assurance and Performance Improvement (QAPI) program documentation indicated a commitment to setting and measuring progress toward performance goals, but the identified deficiencies and incomplete corrective actions demonstrated a failure to achieve compliance.