A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
A resident’s CCP was not revised to reflect the correct advance directive status after Hospice admission and a DNR order were obtained. The resident had a BIMS score of 14, required extensive to total ADL assistance, and was receiving Hospice services, but the CCP still listed full code and advance directive entries showing no change. The SW confirmed the CCP should have been updated to no code after the facility received the DNR paperwork and Hospice documents.
A resident with moderate cognitive impairment and diagnoses including dementia, frontal lobe/executive function deficit, depression, and anxiety was repeatedly identified as high elopement risk, but the care plan did not include an elopement risk focus or any interventions. Staff confirmed the resident was on the elopement list, an alarm was attached to the room door, and the ADON acknowledged the care plan update had not been completed.
A resident with multiple medical conditions and intact cognition required total staff assistance and had clearly communicated preferences for morning and evening routines during a care plan conference attended by their spouse. Despite this, the care plan was not updated to include the resident's preferred times for getting up and going to bed, as confirmed by the DON.
The facility did not complete or document required care plan conferences for three residents, including those with Multiple Sclerosis and varying cognitive statuses. Residents reported not being involved in care planning, and staff confirmed that care conferences were delayed or missing, with no consistent scheduling or notification process in place.
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.
A resident with multiple serious diagnoses was admitted to hospice, but the facility did not update the comprehensive care plan to include specific hospice-related objectives, goals, or interventions as required. The care plan only noted a terminal prognosis and listed a hospice nurse's contact, without further detail. The DON confirmed the care plan was not revised to address hospice needs.
A resident with a history of falls and mental health conditions experienced a decline in ADLs after a fall and surgery, requiring increased assistance with daily tasks. Despite staff providing this assistance and updated MDS assessments reflecting the change, the comprehensive care plan was not revised to document the resident's new needs.
A resident with moderate cognitive impairment was found to have bed canes in use without documentation or care plan inclusion, despite facility policy requiring clinical indication for such equipment. The resident was unaware of the reason for the bed canes, and the ADON confirmed the omission in the care plan.
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