A facility failed to keep care plans updated for three residents with changed needs. One resident with a suprapubic catheter had no care plan focus for catheter care, catheter changes, or infection monitoring; another resident taking mirtazapine for depression had no care plan details for the medication, nonpharmacologic interventions, depression symptoms, or adverse effects; and a third resident receiving comfort care had no care plan interventions for end-of-life needs, including fear of dying, terminal restlessness, positioning, reorientation, or family education.
A resident eloped from the facility without staff knowledge by exiting through an alarmed door that had been deactivated by a vendor. Following the incident, staff reported that the care plan would be updated after an IDT review, and facility documentation stated the plan would reflect a need for closer monitoring and supervision near exits. However, the actual care plan revision only included adding the resident to an elopement binder, providing education about not leaving without assistance, encouraging use of an enclosed patio, and general wandering/elopement interventions, without specifying closer supervision at exits. This failed to align with the facility’s own elopement policy requiring that risk-related interventions be incorporated into the care plan and communicated to staff.
The facility did not update the comprehensive care plans for two residents after changing their incontinence products from disposable to reusable liners. Both residents expressed dissatisfaction with the new products, reporting increased accidents, but their care plans were not revised to reflect the new interventions, education provided, or the residents' concerns.
The facility did not update care plans for several residents after fall incidents, failing to add new interventions or address root causes as required. Multiple residents experienced falls with injuries, but care plans were not revised, event forms were incomplete, and root cause analyses were not performed. Staff interviews indicated unclear processes and communication gaps regarding care plan updates after falls.
A resident with a left below-knee amputation refused to wear a prescribed brace, leading staff to use a compression wrap to secure the stump to the wheelchair leg rest. The care plan was not updated to reflect the resident's refusal, the use of the compression wrap as a restraint, or related risks, despite facility policy requiring such revisions.
A resident's care plan was not updated to reflect changes in transfer ability after new PT documentation indicated transfer goals were discontinued due to pain and lack of participation. The care plan continued to state the resident could transfer with assist of one, despite evidence to the contrary, and the resident later sustained a hematoma likely related to a difficult transfer. Staff interviews confirmed the care plan was not revised as required.
A resident's care plan was not updated to address sexual behaviors directed towards others, despite an incident involving inappropriate contact between two residents. The care plan only included interventions for bipolar disorder symptoms and did not address the new behavioral concern, contrary to facility policy requiring care plan revisions after a status change.
A resident receiving telehealth mental health services for PTSD did not have these services reflected in their comprehensive care plan. Staff confirmed that care plans should address mental health concerns and interventions, but the plan only included medication management and monitoring, omitting the behavioral health services being provided.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not update care plans to reflect the specific activity preferences and participation of two residents, nor did it include enhanced barrier precautions for a resident with an indwelling urinary catheter. Staff interviews and record reviews showed that individualized interventions and infection control measures were missing from the care plans, despite observations of resident needs and facility policy requirements.
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