Failure to Update Care Plan After Significant Weight Loss
Summary
The facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident. The resident, identified as #162, experienced a 10.53% weight loss, which was not addressed in the care plan. The care plan, last updated prior to the weight loss, included interventions such as dietician evaluations and medication administration but did not reflect the recent significant weight change. Observations and interviews revealed that the resident had a history of variable intake and meal refusals, which were not adequately addressed. The resident's family noted a significant decrease in the resident's eating habits. Staff interviews indicated that the resident consistently ate less than 25% of meals, yet this was not communicated effectively to the nursing staff or reflected in the care plan. The facility's Registered Dietician confirmed that the resident's significant weight loss was documented but not followed up with appropriate care plan updates or interdisciplinary team meetings. The dietician had recommended supplements, but there was no evidence of a revised care plan or additional interventions to address the resident's nutritional decline. The lack of communication and coordination among staff contributed to the failure to update the resident's care plan appropriately.
Plan Of Correction
The facility residents with significant loss have the potential to be affected by not revising the care plan with changes and new interventions. Residents with a significant loss will be reviewed by the Registered Dietitian/Designee to determine if a significant change assessment and or care plan revision is needed. Revisions and updates will be completed as indicated. The Director of Nursing / Designee will educate the Registered Dietitian, Dietary Tech, Minimum Data Set Coordinators on the need to complete an assessment, and revise the care plan with new interventions for residents with a significant change in status in loss so that the care plan accurately reflects the resident. The Director of Nursing/Designee will complete 3 random weekly audits on loss to determine if the care plan accurately reflects the residents significant loss and/or if revisions are needed. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Penalty
The facility did not timely update or revise care plans for two residents after significant changes in condition and medication orders. One resident experienced a fall and injury during a wheelchair transfer, but the care plan was not updated to address the incident. Another resident's care plan did not reflect changes in diagnoses or medication regimen, and a care plan for a new condition was not developed. Staff interviews confirmed gaps in care plan updates and documentation.
A resident was incorrectly coded in the MDS as being discharged to a hospital instead of an Assisted Living Facility. The error was identified through a review of clinical records and discharge assessments, which showed a discrepancy between the MDS coding and the nurse's notes. The MDS Coordinator acknowledged the mistake, citing a lapse in the verification process between the Social Services and MDS departments.
A resident was discharged home, but the MDS inaccurately coded the discharge status as to an acute hospital. The error was identified during a review of the resident's records, revealing a discrepancy between the actual discharge and the documented status. The MDS Coordinator confirmed the miscode upon review.
A resident with multiple diagnoses was discharged home as documented in care plans, progress notes, and social services records. However, the MDS discharge assessment incorrectly recorded the discharge status as 'Short-Term General Hospital' instead of home. The MDS Coordinator confirmed the error and indicated the assessment would be updated.
The facility failed to maintain accurate MDS records for two residents, leading to deficiencies in their care plans. One resident was incorrectly coded as a hospice resident without hospice orders, and another was inaccurately coded as returning to a hospital instead of being discharged to an ALF. These errors highlight lapses in documentation and communication within the facility.
Two residents with severe cognitive impairments experienced falls due to inadequate care plans and supervision. One resident, dependent on staff for daily activities, had multiple falls without necessary interventions like frequent checks. Another resident's care plan included a dycem to prevent sliding from a wheelchair, but it was not consistently used, leading to falls. The facility failed to update care plans and ensure staff were informed of necessary interventions.
Failure to Timely Update and Revise Care Plans Following Changes in Resident Condition and Medication
Penalty
Summary
The facility failed to revise and update care plan interventions in a timely manner for multiple residents, as required by state regulations. For one resident, after experiencing a fall while attempting to transfer between wheelchairs, the care plan was not updated to reflect the incident or to address the new safety concerns. The resident, who had a history of vision impairment and mobility issues, reported that the fall occurred due to a malfunctioning wheelchair lock and confusion during the transfer process. Despite documentation of the incident and the resident's injuries, the care plan remained unchanged, and staff interviews revealed uncertainty about who was responsible for updating care plans following such events. Another resident's care plan was not revised to reflect changes in diagnoses and medication orders. The resident had multiple discontinued and current medication orders, including psychotropic drugs, but the care plan did not accurately address the resident's current medication regimen or associated diagnoses. Interviews with nursing and MDS staff confirmed that there was no documented diagnosis for some of the medications administered, and care plans were not consistently updated to reflect medication changes or discontinuations. The facility's policy required that information from ongoing evaluations be incorporated into the comprehensive care plan, but this was not consistently followed. Additionally, the same resident did not have a care plan developed or implemented to address a newly identified condition. Both the Regional MDS Coordinator and the Assistant MDS Coordinator acknowledged the absence of a care plan for this condition during interviews. The lack of timely and accurate updates to care plans, as well as the failure to develop care plans for new diagnoses, constituted noncompliance with regulatory requirements for comprehensive, person-centered care planning.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with alleged deficiencies herein. To remain compliant with all federal and state regulations, the facility has taken actions set forth in the plan of correction. The plan of correction constitutes the facility's allegation of compliance such as the deficiencies cited have been corrected by the date certain. On the DON updated the care plan and added the appropriate intervention for resident #92. On the regional reimbursement coordinator revised and updated the care plans for the changes of diagnosis and medications for resident #76. On the regional reimbursement coordinator initiated the care plan for resident #76. On [date], the Regional Nurse Consultant conducted a quality review of residents who have had a [specific event or condition] in the past 30 days to ensure that interventions are added to the care plan timely. Follow up based on findings. On [date], the Regional Reimbursement Coordinator conducted a quality review of residents with new active diagnosis or medication changes in the past two weeks to ensure that care plans were appropriately developed or updated. Follow up based on findings. On [date], the Regional Nurse Consultant conducted a quality review of current residents with the diagnosis of [diagnosis] to ensure that appropriate care plans have been developed. No additional findings noted. By [date], the licensed nurses including the MDS nurses were educated by the Staff Development Coordinator on the components of N071 with an emphasis on accurate revisions and updating of care plans. As a systematic change, newly hired licensed nurses, including MDS nurses, will be educated on the components of N071 with an emphasis on accurate revisions and updating of care plans. The DON/designee will conduct quality monitoring audits of 10 random residents weekly for 4 weeks, then 10 random residents monthly for 2 months to ensure proper revision and updating of the care plans. The findings of these quality monitoring audits are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
MDS Coding Error for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, resulting in a discrepancy in the discharge information. The resident, who was initially admitted from a Short-Term General Hospital with a medical diagnosis of other specified injuries, was scheduled to be discharged to an Assisted Living Facility (ALF). However, the MDS was incorrectly coded to indicate that the resident was discharged to a Short-Term General Hospital instead of the ALF. The error was identified during a review of the resident's clinical records and discharge assessment. The discharge assessment MDS reference indicated a planned discharge, but the section for discharge status incorrectly coded the resident as being discharged to a hospital. This was contrary to the nurse's notes, which documented that the resident was discharged to the ALF and transported via wheelchair. During an interview, the MDS Coordinator acknowledged the error, explaining that the Social Services department is responsible for inputting discharge information, while the MDS department verifies the timely submission of this information. The coordinator accepted responsibility for the error on behalf of the department. The facility's policy requires a complete admission observation/assessment to develop a care plan tailored to the resident's needs, with ongoing assessments throughout the resident's stay.
Plan Of Correction
Immediate Action: The Minimal Data Set dated for sample resident #200 was modified for discharge status to an Assisted Living Facility in section A 2105 on was resubmitted on. Responsible staff member was re-educated on accurate Minimal Data Set completion by the MDS Nurse. Identification of Residents with potential to be affected: All residents that are discharged have the potential to be affected. The discharge assessment- return not and return MDSS completed since will be audited for discharge location accuracy and modified per Resident Assessment Instrument Manual. Inaccuracies identified will be corrected and resubmitted. System Changes: All resident discharges will be discussed by the Interdisciplinary Team on the next business day to determine discharge disposition. Discharges will be completed by the MDS Nurses in the entirety as of. Monitoring: Monthly audits of all Discharge Assessments will be audited weekly for accuracy for the next 3 months. An audit sheet will be maintained to demonstrate accurate completion of section A2105. Results will be reported monthly to the Quality Assurance Performance Improvement committee. At the end of 3 months, the Quality Assurance Performance Improvement Committee will reassess the need for ongoing audit frequency and duration. Responsible Party: MDS Nurses/ Coordinators
MDS Coding Error in Resident Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a discrepancy in the discharge status. The resident was discharged home, but the discharge assessment incorrectly indicated that the resident was discharged to an acute hospital. This error was identified during a review of the resident's medical records and MDS documentation. The resident in question had been admitted to the facility with various medical diagnoses. The MDS dated for the resident showed a perfect score in Section C, indicating the resident's cognitive patterns were intact. However, the discharge status was inaccurately coded, reflecting a discharge to a short-term general hospital instead of the resident's actual discharge to home. An interview with the MDS Coordinator revealed that she was initially informed of the resident's discharge to home. Upon reviewing the records, the miscode was identified. The facility's policy and procedure for resident assessments require comprehensive assessments to identify care needs and develop an interdisciplinary care plan, which was not accurately reflected in this instance.
Plan Of Correction
regulations and statutes applicable to long term care providers. This POC does not constitute an admission of liability on the part of the facility and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency or that the scope or severity regarding any of these deficiencies cited are correctly applied. The corrective action accomplished for those residents identified: On Resident #109 Discharge - retum not MDS dated was modified and uploaded to IQIES on and accepted. Resident #109 was not negatively affected by the data entry error. No other residents were affected or identified. Other residents having the potential to be affected were identified by: In order to identify any potential residents affected by MDS data entry errors an audit was conducted by the Administrator during on discharge MDSs for those residents discharged return and return not. The measures of systematic changes made include: MDS Coordinator (Staff B) was reinserviced on and the additional MDS Coordinator was reinserviced on regarding the accuracy of MDS coding especially related to discharge residents. In addition, the in-service also reviewed the EMR system and location of information available to assist in accuracy of coding. The Administrator will conduct random audits weekly for 1 month, then monthly for 2 months. The corrective actions put in place include: The Administrator or designee will monitor overall compliance of the MDS accuracy of discharge assessments. Any findings identified will be corrected and reported to the Director of Nursing and QAPI/QAA Committee until substantial compliance is achieved and maintained. The Director of Nursing or designee will monitor ongoing compliance through random audits.
Inaccurate Documentation of Resident Discharge Status
Penalty
Summary
The facility failed to accurately document the discharge status of a resident, as required by 59A-4.109(1), FAC, which mandates a comprehensive and accurate assessment of each resident's functional capacity and discharge status. The resident in question was admitted with diagnoses including wasting and atrophy, abnormalities of gait and mobility, and was documented in the care plan as wishing to return home. The care plan goal was to safely discharge the resident to a lower level of care, such as home, when rehabilitation goals were met. Progress notes and social services documentation confirmed that the resident was discharged home, with details indicating the resident left the facility via private car, accompanied by two persons, and received food and medication as ordered prior to departure. The resident was alert, oriented, and independent in decision-making, and had requested to be discharged home to coincide with the discharge of a spouse from the hospital. Durable medical equipment was ordered for the resident prior to discharge. Despite this, the Minimum Data Set (MDS) discharge assessment inaccurately recorded the resident's discharge status as 'Short-Term General Hospital' instead of home. During an interview, the MDS Coordinator confirmed the resident was discharged home and acknowledged the error in the MDS assessment, stating that it would be updated and resubmitted.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to maintain accurate Minimum Data Set (MDS) records for two residents, leading to deficiencies in their care plans. Resident #24 was incorrectly coded as a hospice resident in the MDS, despite having no hospice orders in their medical records. This discrepancy indicates a lack of accurate documentation and communication within the facility regarding the resident's care status. The resident's medical history included surgical aftercare, but there was no care plan related to hospice, highlighting a significant oversight in the resident's care documentation. Similarly, Resident #89 was inaccurately coded in the MDS as having a planned return to a short-term general hospital, although the resident was actually discharged to an Assisted Living Facility (ALF). The medical records and physician's orders confirmed the discharge to an ALF, yet the MDS did not reflect this change. This error suggests a failure in updating the resident's discharge status accurately, which is crucial for ensuring continuity of care and appropriate resource allocation. Interviews with the MDS Coordinator revealed that there was an oversight error in the communication process between departments, including nursing, social services, and billing. The coordinator acknowledged the need for modifications to correct these inaccuracies. The facility's policy requires timely and appropriate resident assessments, but the errors in the MDS coding for these two residents indicate a lapse in adherence to these procedures, resulting in the noted deficiencies.
Failure to Implement Adequate Care Plans and Supervision
Penalty
Summary
The facility failed to revise and implement appropriate interventions for two residents, leading to deficiencies in their care. Resident #3, who had severe cognitive impairment, hearing loss, and vision issues, experienced multiple falls. Despite being dependent on staff for various activities, the care plan did not include necessary interventions such as frequent checks or appropriate supervision. The resident's care plan was not updated to reflect her need for constant supervision, and interventions like offering toileting after meals were not implemented. The resident's daughter expressed concerns about the lack of supervision and the resident's tendency to attempt activities independently, which were not adequately addressed by the facility. Resident #51, who also had severe cognitive impairment and required substantial assistance for daily activities, experienced falls in the facility's TV room. The care plan included the use of a dycem to prevent sliding from the wheelchair, but it was not consistently used or documented in the resident's care plan. Staff were unaware of the dycem's absence, and the resident's care plan did not reflect the need for increased supervision during times of behavioral changes. The facility's failure to ensure the dycem was used and to provide adequate supervision contributed to the resident's falls. The facility's policies on accidents and supervision, as well as comprehensive care plans, were not effectively implemented. The guidelines required communication and documentation of interventions across all disciplines, but this was not done. The care plans for both residents lacked necessary interventions, and staff were not adequately informed of their responsibilities. The facility's failure to update care plans and ensure staff were aware of and implemented necessary interventions led to the deficiencies observed.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: New risk evaluations were completed for Resident #51 to reflect accurate information, and their care plans and Kardex's were updated to reflect accurate risk assessments, with appropriate and individualized prevention interventions implemented. Resident #3 is no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. The MDS Coordinator and Unit Managers conducted a facility-wide audit of risk assessments and care plans for residents with a score of 12 or less to identify any discrepancies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) staff will receive mandatory training regarding review and use of Care Plan/Kardex prior to providing care to Residents. This education will also be completed upon hire and at least annually. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. Starting on all Licensed nurses (RNs and LPNs) and MDS staff on the proper completion of risk assessments, individualized care planning, and the importance of ensuring interventions are documented in the Kardex. All Licensed nurses (RNs and LPNs) and MDS staff will be in-service by. Any Licensed nurses (RNs and LPNs) and MDS staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed nurses (RNs and LPNs) and MDS staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or Designee will review a sample of five residents risk evaluations, care plans and Kardexs weekly for four weeks, then monthly for three months to ensure continued compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) Date of compliance
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