Failure to Update Care Plans for Comfort Care and Pressure Ulcers: The facility did not revise the care plan for a resident placed on comfort care after a clinic visit showed worsening fluid retention, cough, swelling, and decreased strength; the plan omitted the no-hospitalization order, discontinuation of labs, and guidance for comfort if the resident declined. The facility also failed to update another resident’s care plan after the MDS identified four Stage II pressure ulcers, leaving only general skin-risk interventions instead of wound-specific goals and treatment measures.
Care plans and related care guides were not updated for a resident with pain, a resident with recurrent falls, and a resident with severe cognitive impairment and transfer needs. One resident’s plan lacked individualized nonpharmacological pain interventions, another resident’s plan omitted a motion sensor that staff were using for fall prevention, and a third resident’s plan and Kardex incorrectly stated the resident was independent with transfers despite staff using a transfer belt and Hoyer lift with two-person assistance.
Failure to revise care plans for two residents left key safety and behavior needs undocumented. One resident with dementia had scissors removed after cutting clothing and hair, but the care plan did not include supervised scissor use. Another resident with a wander guard repeatedly wanted to go outside and attempted to go out on his own, but the care plan did not identify elopement risk or specific interventions for staff. Interviews confirmed staff knew about both residents’ needs, yet the care plans did not reflect those changes.
A resident with moderate cognitive impairment and a progressive neurologic condition had conflicting mobility documentation, including care plan and Kardex entries showing both non-ambulatory status and an active ambulation program. Staff interviews and a progress note showed the resident had stopped ambulating with nursing staff and the restorative program was no longer active, yet the restorative care plan still listed ambulation tasks and had not been updated to reflect the change in status.
Failure to hold required care conferences for a resident with TBI, seizure disorder, depression, opioid dependence, legal blindness, and dizziness. The resident’s EHR had no documentation of care conferences since admission, and the resident said she did not remember being invited or involved in any meetings about her care. The SS director confirmed the missing documentation, while staff stated conferences were expected within 48 hours of admission, quarterly, and as needed, with the resident and family invited.
Failure to revise a resident's care plan for a new pressure ulcer. A resident with moderately impaired cognition, lower-extremity limitations, and diagnoses including HF, arthritis, and depression developed a stage 2 pressure ulcer on the left 2nd toe. The skin assessment noted the resident was educated to leave the shoe off to relieve pressure, but the care planning section was blank and the care plan did not include that intervention, even though nursing documentation showed the wound was assessed and the care plan was reviewed.
Care plans were not updated to reflect ordered FMPs for two residents receiving restorative exercise programs, including goals and staff interventions tied to strengthening, transfers, standing, and ambulation. One resident had severe cognitive impairment and could not ambulate, while another was cognitively intact but required substantial to maximal assistance with bed mobility and transfers. The facility also did not include EBP details in another resident’s care plan despite staff stating gown and gloves were used for direct care with a g-tube.
A resident with vascular dementia, aphasia, hemiplegia/hemiparesis, depression, anxiety, and a history of stroke and temporal lobectomy had a care plan that listed ROM/PROM with AM/PM cares and did not identify a right-hand splint. However, the assignment sheet and task tab did not direct staff to provide ROM or note the splint, the resident said staff did not help with exercises to the right side, and staff interviews showed the actual restorative nursing ROM schedule differed from what the care plan reflected.
The facility failed to ensure person-centered care plans accurately reflected all medical devices in use and resident preferences for three residents. One resident with significant cognitive impairment and multiple neurologic conditions had head and foot side rails, a seat belt alarm, and a wander guard in use, but the care plan omitted the foot rails, did not specify when to release the seat belt, and did not list the wander guard. Another severely cognitively impaired resident with extensive ADL needs used bilateral quarter side rails, a seat belt alarm, and a wander guard, none of which were documented on the care plan, while staff relied on general training and common practice rather than individualized care plan guidance. A cognitively intact resident with stroke-related conditions had a care plan listing a bed alarm and wheelchair alarms, but his stated lack of consent and discomfort with the bed alarm, including its impact on his sleep and concern for disturbing others, was not reflected in the care plan, contrary to facility expectations and policy.
The facility failed to update comprehensive care plans for two residents. One resident with dementia and prior skin issues had care plans that were not revised when MASD resolved and when new stage 3 pressure injuries developed on the coccyx and right lateral midfoot. Another resident’s care plan still listed a hearing amplifier even though the resident did not have or use one, despite documented hearing loss and staff observations confirming no hearing device was in use.
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