A resident with Alzheimer’s disease, severe cognitive impairment, and a history of falls was observed in a bed left in a high position with the call light out of reach, despite a care plan and physician orders for fall precautions and keeping the bed in the lowest position. The CNA acknowledged forgetting to lower the bed, and the RN, nursing supervisor, and DON confirmed that the bed should be low when staff are not present.
The facility failed to consistently review and revise comprehensive care plans after multiple behavioral incidents, resident‑to‑resident altercations, and falls. One resident with dementia and PTSD experienced repeated verbal altercations and a fall with head impact after yelling at others near an exit door, yet his behavioral and fall care plans were not updated with new approaches. Another resident with severe cognitive impairment and daily wandering was involved in several altercations related to wandering, but his existing behavior and wandering care plans were not revised to reflect these events. A third resident with dementia had documented episodes of yelling at a roommate and attempting to trip another resident, without corresponding care plan updates. A fourth resident with dementia, agitation, and PTSD‑related psychosis had multiple falls and a resident‑to‑resident incident, but his fall care plan had not been recently updated. The MDS RN and DON confirmed that these care plans were not revised after the incidents, despite facility policy requiring care plan review and revision when significant changes or unmet outcomes occur.
Oxygen Delivered Above Ordered Rate: Two residents who were dependent on supplemental oxygen were observed receiving oxygen above the physician-ordered rate. One resident with chronic respiratory failure, pneumonia, and dependence on oxygen was found on nasal cannula at 3.25 LPM instead of the ordered 2 LPM with humidification, and another resident with acute and chronic respiratory failure and pneumonia was found at 2.75 LPM instead of the ordered 2 LPM. An RN verified the orders and acknowledged the oxygen was not being administered at the prescribed rate.
A resident with end stage liver disease, hepatocellular carcinoma, CHF, COPD, diabetes, and hypertension required oxygen therapy per physician and pulmonary specialist orders, including specific LPM ranges and directions to maintain SpO2 above 92% and use oxygen at night. Facility records showed ongoing oxygen use and weekly tubing changes, but no corresponding comprehensive care plan for oxygen therapy was developed. The resident was observed on oxygen via nasal cannula at 5 LPM, above the ordered 2–4 LPM PRN, and an RN reported that the resident or her son sometimes adjusted the flow rate. The DON and MDS Coordinator both confirmed the absence of an oxygen care plan despite daily order review and a policy requiring care plans for all services identified in the comprehensive assessment.
A resident with dementia, seizure disorder, right foot drop, heart failure, and other conditions had a physician order and care plan intervention for bilateral floor mats at the bedside when in bed due to fall risk. Surveyor observations on multiple occasions found only one floor mat placed on the right side of the bed, with no mat on the left side. A CNA reported not knowing the resident should have mats on both sides and stated the resident had always had just one mat, while an RN needed to verify the order. The DON stated that staff are expected to follow physician orders and that the resident should have mats on each side, demonstrating the facility’s failure to implement the comprehensive, person-centered care plan as written.
Surveyors found that the facility failed to follow care plan interventions for two residents: one who used a scoop plate for eating and another who required a call light within reach. A resident with CVA-related hemiparesis, dysphagia, and dementia was repeatedly served meals with the high side of the scoop plate positioned away from him, causing food to be scraped off the plate, while staff did not adjust the plate and the meal ticket lacked instructions on proper positioning. Another cognitively intact resident with multiple neuropsychiatric diagnoses and an ADL self-care deficit was observed several times in bed with her call light on the floor or clipped to the back or top of her pillow, out of reach, despite a care plan requiring the call bell and call light to be kept within reach in her room and bathroom.
Failure to Individualize UTI Care Plan: A cognitively intact resident with a UTI had lower abdominal pain and dysuria, with urine culture results showing E. coli and an order for Macrobid. The baseline care plan only noted an infection and listed contact isolation, droplet isolation, and standard precautions without identifying the specific infection or which precautions were appropriate; the RN MDS Interim Coordinator confirmed the care plan was not resident-specific or individualized.
A resident with dementia, behavioral disturbances, and a documented diagnosis of high-risk heterosexual behavior had a care plan addressing depression, dementia, and hypersexual behaviors, including interventions to anticipate needs, protect others, monitor behaviors, and document episodes. However, staff interviews and records showed the plan was not effectively implemented: a CNA discovered the resident in another resident’s room with the other resident’s brief pulled down and the resident’s hand against the other resident’s genital area while the resident’s penis was exposed, and a prior inappropriate interaction between the same two residents in the dining room had gone unreported. The DON, an LPN, and CNAs, including one assigned to 1:1 supervision, were unaware of the hypersexual diagnosis, specific behaviors to monitor, or the reasons for enhanced supervision, and an observation later found the resident in the dining room without continuous 1:1 supervision, contrary to the documented behavioral concerns and facility policy requiring that staff be informed of their care plan responsibilities.
A resident with dementia, behavioral disturbances, and anxiety was involved in a reported sexual incident with a female peer. The care plan was updated to note that the resident could be sexually inappropriate and to include enhanced monitoring by staff, but progress notes contained no documentation of 1:1 supervision, enhanced monitoring, or continuous monitoring during the relevant period. Interviews with the DON, ADON, and an RN/UM showed conflicting understandings of the terms 1:1 supervision and enhanced monitoring, and differing views on whether a physician order was required, while all indicated that such supervision should be reflected in the care plan and documented in progress notes. This inconsistency and lack of documentation demonstrated that the comprehensive care plan interventions for supervision were not effectively implemented.
A resident with bipolar disorder, morbid obesity, and muscle wasting was documented as blind or severely visually impaired, yet her care plan had no interventions for vision loss. The hospital transfer form, MDS, nurse note, and SSD notes all reflected significant vision impairment and a pending cataract surgery issue, but staff confirmed the impairment was not included in the care plan and that the resident signed paperwork without family being called to explain it.
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