A resident with a history of TBI, hemiplegia, and bipolar disorder repeatedly complained that a specific CNA was slow to respond, rude, and problematic during cares. Grievance forms documented that the resident requested the CNA not provide care, agreed to 2-hour rounding in pairs, and that cares in pairs would be implemented for night cares, with the form indicating the care plan was updated. However, review of the Comprehensive Care Plan showed no revisions since the prior year and no interventions reflecting paired staffing or altered care approaches related to these grievances. The ADM acknowledged the CCP was not revised, treated the issue as a personnel matter rather than a care-planning issue, and progress notes contained no documentation of the staffing changes, while the resident reported that the CNA continued to enter the room and that grievances did not result in effective changes.
A resident with DM who received insulin did not have a comprehensive care plan that addressed diabetes care. The care plan lacked a focus area for DM and did not identify monitoring for signs of high or low blood sugar, and the DON confirmed the omission.
Failure to Include Ordered Fluid Restrictions in Care Plans: Two residents had physician-ordered fluid restrictions that were not included in their CCPs. One resident had a 1.5 L daily fluid restriction, and another resident with HTN, a BIMS score of 11, and supervision needs had an order for a fluid restriction related to HTN, but neither care plan addressed the nutritional intervention. The MDS Coordinator confirmed the omissions.
A CCP failed to include a resident’s stated discharge goal to return home after a stage 3 pressure ulcer healed, even though the resident and spouse both identified that plan. Another resident’s CCP did not match the current pureed diet order and also omitted the resident’s antipsychotic medication use and monitoring needs, despite MDS, physician orders, EMAR, and staff interviews confirming the diet change and ongoing Risperidone administration.
Failure to implement a comprehensive nutrition care plan. A resident with severe cognitive impairment, extensive assistance needs, and about 50% meal intake had a baseline plan for a mechanical soft diet and eating assistance, but the comprehensive care plan did not include altered nutrition. The RD confirmed the nutrition care plan should have been in place earlier but was not implemented until later.
The facility did not ensure that care plans were individualized, person-centered, or included measurable goals and interventions for residents with complex needs such as respiratory infections, diabetes, nutrition, UTIs, and fluid restrictions. For example, a resident with ongoing respiratory issues had a care plan that only addressed antibiotics and oxygen, while another with diabetes and significant weight gain had no care plan interventions for nutrition or education. Staff interviews confirmed that care plans were not consistently updated to reflect residents' current needs or preferences.
Two residents' care plans did not address all required needs: one resident's plan omitted prescribed antidepressant medications despite a diagnosis of major depressive disorder, and another resident's plan failed to include discharge planning even though a discharge order was present. The DON and SSD confirmed these omissions during interviews.
A resident with dementia, anxiety disorder, and PTSD was admitted and exhibited confrontational behavior and war-related hallucinations. The MDS assessment failed to include PTSD as a diagnosis, and the care plan did not address the resident's PTSD, despite facility policy requiring all identified needs to be included. Staff confirmed the omission, resulting in the resident's mental health needs not being fully addressed.
Two residents with complex medical and mental health needs did not have complete care plans addressing all their diagnoses and high-risk medications. One resident's care plan lacked non-pharmacological interventions for anxiety and did not mention all prescribed psychotropic medications, while another resident's care plan omitted key conditions such as CHF, diabetes, and the use of antiplatelet and diuretic medications. These omissions were confirmed by facility leadership and did not align with the facility's care planning policy.
Two residents with orders for oxygen therapy and respiratory treatments did not have their respiratory care needs addressed in their comprehensive care plans, despite facility policy and physician orders requiring such documentation. Observations confirmed the use of oxygen and nebulizer equipment, and staff interviews acknowledged the omission of these needs from the care plans.
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