The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
Care plans were not developed and implemented to reflect the current needs of two residents. One resident with Alzheimer's disease, suicidal ideations, delusional disorder, mood disorder, and bipolar disorder had an active order for quetiapine, but no care plan for antipsychotic use. Another resident with chronic pain and depression had active orders for sertraline, methadone, and PRN oxycodone, but the care plan lacked goals, interventions, and side effect monitoring for pain management and antidepressant use.
A resident with a history of stroke and left-sided weakness, including a flaccid left arm, had a care plan for functional mobility that required two staff for all transfers. Despite this, a CNA attempted to transfer the resident alone from a wheelchair to a bed, the transfer failed, and the CNA lowered the resident to the floor. The resident was assessed with no visible injuries, and both the CNA and the Administrator later confirmed that the care plan requiring two-person assistance for transfers was not followed.
Surveyors found that the facility failed to develop, update, and implement accurate care plans for multiple residents. Two residents were repeatedly transferred by CNAs using manual stand-pivot techniques under the arms, despite existing ADL care plans and CNA assignment sheets requiring use of a mechanical lift, sit-to-stand device, or specified assistive equipment and staffing levels. In addition, a resident receiving hospice/palliative care had no corresponding hospice or palliative care plan or interventions in place, and another resident who was always incontinent of bowel and bladder per the MDS had no care plan addressing incontinence. The DON confirmed that these care plans did not reflect the residents’ current needs.
A resident with dementia, visual loss, and a history of falls was not provided with hip protectors as required by their care plan and physician orders. Staff interviews revealed a lack of awareness and follow-through regarding this intervention, and it was confirmed during the survey that the resident was not wearing hip protectors, despite being at high risk for falls.
A resident with dementia and anxiety suffered a leg fracture, but the care plan was not updated with new goals or interventions following the injury. Review of records showed the care plan had not been revised to address the resident's new needs after the incident.
Two residents requiring wound care did not have care plans developed to address their wounds, including the absence of documented goals and interventions. One had a chronic abscess with new antibiotic orders and wound packing, while the other had wounds on both feet, including an unstageable pressure ulcer. These deficiencies were confirmed by record review and staff interviews.
A resident who required full assistance for transfers was observed using a large (green) sling instead of the care-planned medium (purple) sling for mechanical lift transfers. Multiple CNAs relied on the Kardex and sling color coding to select sling size, but the resident was not in the correct sling as specified in the care plan, a fact confirmed by the Regional Administrator.
A resident with dementia who was at risk for elopement became agitated and attempted to leave the facility. Staff failed to follow the care plan interventions, including using a calm approach and providing diversions, and the section for the resident's preferences was left blank. Instead, an RN escalated the situation by yelling and mimicking the resident, resulting in increased agitation and disruption.
A resident with MS, muscle weakness, and a Stage III pressure ulcer, who required total assistance by two staff for transfers and repositioning, experienced a fall with injury after a CNA, unfamiliar with the care plan and lacking proper information, attempted to reposition the resident alone and left the bed in a raised position. The CNA did not review the care plan or Kardex and relied on inconsistent verbal instructions, resulting in the resident being left unsafely and subsequently falling.
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