Two residents experienced falls when staff did not follow individualized care plan interventions. One resident with moderately impaired cognition and an order for a total mechanical lift with two-person assist was transferred using a sit-to-stand lift after a CNA relied on the resident’s verbal report instead of the documented transfer status, leading to a fall during the transfer. Another resident with dementia and severely impaired cognition, care planned for bed and chair alarms due to a history of falls, was found on the floor with the bed alarm not sounding, despite orders to check alarm operation and placement each shift. The DON stated that care plans are communicated via care profiles, and the QA nurse identified failure to follow these care plans as the cause of both incidents.
Staff did not follow care plan interventions for three residents. One resident with edema was observed without ordered compression hose, a CNA provided peri-care to a resident on EBP without a gown, and suction equipment for a resident who self-suctions was observed dirty and outdated while family was performing the cleaning and tubing care instead of nursing staff. The DON confirmed the care plan and orders were not being followed as documented.
A facility failed to carry out care plan interventions for ADLs and wound care for three residents. One resident with a self-care deficit had long, dirty fingernails despite a care plan for daily nail care, another resident with a self-care deficit waited about an hour for toileting assistance after requesting a bedpan, and a third resident with wound care orders had multiple missed Dakins solution and packing treatments documented on the TAR. The DON and MDS RN acknowledged the failures to follow the care plans and ordered treatments.
Failure to develop and implement comprehensive person-centered care plans for three residents. One resident with Alzheimer's disease and severe cognitive impairment had unwashed, matted hair and a foul odor, and staff confirmed he needed hands-on bathing and shampoo assistance but was coded as independent. Another resident with dementia and weakness had unclean, matted hair with scalp buildup despite a bathing/showering intervention in the care plan. A third resident who used tobacco had no smoking care plan, and the MDS Nurse confirmed the omission.
Failure to document and implement care plan monitoring interventions for medication side effects. Three residents had care plans that called for observation for side effects or bleeding related to psychotropic or anticoagulant medications, but the records showed no documentation that the monitoring occurred. The residents had diagnoses including Alzheimer’s disease, bipolar disorder, anxiety, depression, and chronic atrial fibrillation, and staff including an LPN, DON, RN, and administrator acknowledged the missing documentation.
A resident with hemiplegia, hemiparesis, and cognitive impairment had a care plan directing staff to apply and remove a right ankle splint at specific times each day and to provide passive stretching to prevent decline in ROM. Observation found the splint not in use and lying on a chair, and the resident was unsure when it was last applied. A PTA reported the resident had developed foot drop and that the splint could no longer be applied without additional therapy, attributing this to the splint not being used daily as ordered. The DON confirmed that staff failed to follow the established care plan for splint application and ROM management.
A resident with Type 2 DM and moderately impaired cognition had two unstageable heel DTIs documented on the MDS and physician orders for treatment to both heels, but the comprehensive care plan did not include any problem, goals, or interventions related to these pressure injuries. LPNs responsible for MDS and care plan completion acknowledged the omission and stated that although they periodically audit by comparing orders to the care plan, this situation was missed. The DON reported she expected the wound care nurse to update the care plan with new wound treatment orders, while an RN stated she could update interventions but had not been trained to create a new focused care plan and was unaware it was her responsibility to add the DTI treatment orders to the care plan.
Failure to Implement Catheter and ADL Care Plans: The facility did not follow care plans for a resident with an indwelling Foley catheter or for several residents who required ADL assistance with grooming and personal hygiene. Observations showed an unsecured catheter for one resident and multiple residents with untrimmed nails, facial hair, disheveled hair, and poor hygiene. The DON and MDS Coordinator confirmed the care plans were not being implemented as documented.
A resident with an ADL self-care deficit and documented need for substantial/maximal assistance with bed mobility had a care plan requiring two staff for turning and repositioning in bed. Despite this, a CNA provided in-bed care and performed a linen and brief change alone, during which the resident rolled to assist, rolled too far, and fell from the bed. The CNA reported attempting to prevent the fall as the resident grabbed the bed rail but could not hold herself up. An X-ray confirmed a proximal humeral fracture of the left shoulder, and facility staff later acknowledged that the established two-person bed mobility care plan had not been followed.
A resident with a history of diabetes mellitus and cerebral infarction developed a new excoriated area on the sacrum that required treatment and monitoring, as documented in progress notes. Facility policy requires comprehensive care plans with measurable objectives, time frames, and service descriptions, reviewed and revised on an ongoing basis. However, record review showed no care plan was developed to address the new sacral skin breakdown. In interviews, an RN stated that care plans are used to guide staff in how to care for residents, and the MDS nurse confirmed that no care plan had been created for this newly identified skin issue, despite acknowledging that one should have been implemented.
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