A resident’s care plan was not revised to include a family member’s request that a specific housekeeper have no contact with or provide care to the resident in a secure unit, despite the family reporting that this housekeeper had previously caused the resident to fall and had been verbally restricted from working around the resident by prior and current leadership. The housekeeping supervisor and the housekeeper confirmed that the housekeeper no longer worked in the secure unit or with the resident, but the MDS nurse reported she was never informed of this change and therefore did not update the care plan, and the ADON confirmed the care plan lacked this information.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
A resident with dementia and behavioral disturbances reported that a male staff member attempted to kiss her forehead, after which it was determined that only female staff should provide her care. Although this change in care preference was documented in a complaint narrative, staff did not revise the resident’s care plan to include the requirement that only female staff provide care, and the DON confirmed that this intervention was not added to the care plan.
Surveyors found that staff failed to accurately revise and update care plans for two residents. For one resident, the care plan for enhanced barrier precautions and vision interventions contained another resident’s name, as confirmed by the DON. For another resident with bipolar disorder, Alzheimer’s disease, cataracts, generalized anxiety disorder, and insomnia, observation showed a fall mat in use by the bed, but the care plan did not document the fall mat, despite the DON’s statement that such equipment must be included in the care plan.
A resident with multiple medical conditions, including epilepsy, depression, HTN, and hypothyroidism, had a completed MOST form indicating DNR status, but staff did not update the comprehensive care plan to include this active code status. The care plan only referenced educating the resident and POA about health directives and having the physician complete a MOST form, despite the existing DNR order. The DON confirmed that advance directives are expected to be included in care plans and acknowledged that the resident’s code status was missing from the care plan.
Surveyors found that staff failed to revise care plans for multiple residents after significant changes in treatment and condition. For one resident with seizures, falls, and sleep apnea, the care plan did not include the use of a camera installed over the bed to monitor seizure activity, did not add interventions after several documented falls, listed an incorrect diet texture, and continued to show continuous O2 therapy even though the resident was no longer on continuous oxygen. For another resident with DM2 and mental health diagnoses, the care plan still directed staff to administer Insulin Glargine even though the insulin order had been discontinued in the medical record.
Staff did not hold or document required IDT care plan meetings for two newly admitted residents after completion of their admission MDS assessments, and their POA/family reported that no meetings had occurred to discuss the residents’ care plans. In addition, another resident’s care plan was not revised to include a documented diagnosis of essential HTN, despite provider notes describing elevated BP readings and treatment with losartan. The DON and Administrator confirmed that these care plan meetings and revisions had not been completed as expected.
A resident’s documented code status was inconsistent across records when staff failed to update the care plan to reflect the resident’s DNR status. The face sheet and NM MOST form identified the resident as DNR, but the care plan listed the resident as Full Code. During interview, the DON acknowledged the advance directive care plan was inaccurate and should have been revised to match the NM MOST.
The facility failed to keep care plans current and to include required IDT members in care plan meetings. For several residents, care plan conferences were held without participation or input from the responsible CNA or the provider, as confirmed by social services staff. One resident who frequently refused showers due to feeling cold or unwell had these refusals reported and documented on shower sheets, but no corresponding interventions or documentation appeared in the care plan. Another resident with painful mycotic toenails and documented orders for nail debridement and routine foot care had visibly overgrown, thick, cracked toenails, and the care plan lacked any interventions for toenail care, despite the DON stating that resident care should be documented on the care plan.
A resident with COPD, DM2, and dementia had a physician order for oxygen at 2 L via nasal cannula to maintain oxygen saturation above 90%. The care plan documented continuous oxygen use at 2 L, but observations showed the resident was not on oxygen and reported using it only when needed. The DON confirmed the resident used oxygen on an as-needed basis and that the care plan had not been revised to reflect this current oxygen intervention, resulting in an inaccurate care plan.
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