A nonverbal resident with a history of brain stem hemorrhage and intact cognition was admitted with documented unclear speech, rare ability to make themself understood, and reliance on nodding, head shaking, and sign language for communication, yet no communication deficit with individualized interventions was initiated on the comprehensive care plan. Multiple assessments and progress notes by nursing, social services, APRN, and SLP consistently described the resident as nonverbal and using alternative communication methods, but these findings were not incorporated into a person-centered care plan. CNAs, an RNA, and an LPN reported using yes/no questions, body language, facial cues, and the resident’s hand signals to communicate, while also stating they did not know sign language and had not seen communication boards or structured tools, and leadership acknowledged that a communication deficit should have been care planned and that there were no facility policies guiding communication care planning for nonverbal residents.
A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls had a care plan requiring two-person assistance with a gait belt for transfers. Despite this, a CNA attempted to transfer the resident alone from a shower chair to a w/c, during which the resident’s knees gave out and the CNA lowered the resident to the floor, causing minor knee scratches documented by an LPN. The administrator later verified that both the care plan and the posted closet care plan specified two-person transfers, while the CNA reported believing the resident was a one-person transfer and admitted not reviewing the closet care plan recently. Other CNAs and a MA-C stated they routinely checked closet care plans, which were updated as needed, to determine residents’ transfer needs.
A facility failed to keep two residents’ care plans current after falls and new interventions were identified. One resident with severe cognitive impairment and a history of falls had post-fall changes such as mattress baffles and assist bars in use, but the care plan did not clearly reflect those interventions. Another resident, who was dependent for transfers and walking and was high risk for falls, had non-skid socks implemented after an unwitnessed fall, but the care plan and Kardex did not include that intervention. The DON, MDS Coordinator, and Administrator all confirmed the care plans were not fully updated to match the residents’ current fall-related interventions.
Care Plan Did Not Address Smoking Safety: A resident with hemiplegia and a TIA/stroke history, who was cognitively intact, used a wheelchair, and was identified as a current tobacco user, had a smoking safety screen showing supervised smoking and 5-10 cigarettes per day. However, the Care Plan did not include smoking, smoking safety, or that the resident smoked. The resident was later observed smoking with supervision, and staff interviews confirmed the Care Plan should have reflected the resident’s smoking needs and that it was inaccurate.
Care Plan Did Not Address High-Risk Medications: A resident admitted with heart failure, stroke with hemiplegia, and a mood disorder received an antidepressant, anticoagulant, and diuretic, but the Care Plan did not include the use, monitoring, or precautions for these medications. The MDS and MAR confirmed the medications were being given, and the MDS Coordinator, DON, and Administrator all confirmed the Care Plan was incomplete and did not address these high-risk drugs.
The facility failed to develop and implement comprehensive care plans addressing sexual health and a consensual sexual relationship for two cognitively impaired, independently mobile residents with psychiatric and neurological diagnoses. Both residents were known to seek each other’s attention and had a prior relationship, yet their care plans only directed staff to separate and redirect them, without any individualized interventions for sexual health, privacy, or safe sex. A CNA later found the two residents on the floor with their pants down, appearing to engage in consensual sexual activity, and they were separated by staff. Subsequent staff interviews confirmed there was no documented assessment, no care plan revisions for sexual health or the relationship, no safe sex education, no established access to contraception, and no facility policy on resident sexual relations.
A resident with dementia, wandering, depression, anxiety, and repeated falls developed new behaviors of crawling, sitting, and lying on the floor, but the care plan did not include these behaviors or interventions for them. Staff documented the behavior in custom notes and stop-and-watch alerts, and interviews with CNAs, an LPN, the DON, and the Administrator confirmed the behavior was known and should have been care planned. The resident’s existing care plan addressed other behaviors and fall risk, but not the new floor-related behavior.
A resident with traumatic brain injury, stroke history, and altered mental status was placed on a secured unit for elopement risk but had only general care plan interventions that were not updated when new wandering, exit‑seeking, and aggressive behaviors emerged. Over time, staff documented that the resident walked the halls at night, entered other residents’ rooms, voiced not living there, stated plans to leave through a window, followed staff through locked doors, and sought ways to get out after a home visit. Despite an elopement assessment and multiple behavior notes, no individualized elopement‑prevention interventions were added to the care plan. Eventually, during a night shift when a CNA reported dozing off and not re‑checking the room, the resident broke a bedroom window with furniture, left the building, and was later found off‑site by police after nearly being hit by a car, confirming that the care plan had not been effectively revised or implemented to address the resident’s exit‑seeking behaviors.
The facility did not update care plans with specific fall interventions after several residents experienced falls, despite their complex medical conditions and histories of falls. Staff interviews confirmed that the process for care plan updates was not followed, and the responsibility for these updates was not fulfilled. The facility's care plan policy was requested but not provided.
A resident with cognitive impairment and mobility deficits, care planned for two-person assistance with a mechanical stand-up lift for transfers, was transferred by a CNA without the required lift or second staff member. During the transfer, the resident fell and sustained a right femur fracture. Staff interviews confirmed the care plan was not followed, and the facility's policy requires adherence to care plan interventions.
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