A resident with MS and polyneuropathy developed new occasional urinary incontinence after previously being continent, but the care plan did not include a focused care area or interventions to address the change. The resident reported not recalling staff prompting toileting at timed intervals, and the DON confirmed the care plan lacked urinary incontinence interventions and that the facility did not have a bladder training or retraining policy.
A resident with psychosis, schizophrenia, and major depressive disorder, initially assessed as not wandering and with moderately impaired cognition, later wandered into another resident’s room and was pushed to the floor, sustaining a bleeding nose, a skin tear, and forehead redness. Following this incident, the medical record did not contain a care plan addressing the new wandering behavior, despite the DON stating that the assigned nurse was responsible for initiating such a plan and describing typical wandering interventions, and despite facility policy requiring ongoing assessment and revision of person-centered care plans as resident conditions change.
A resident admitted with ALS had an activities assessment documenting preferences such as bingo, social events, being outside, one-to-one visits, movies, an iPad, and audiobooks, and was cognitively intact with a BIMS of 15/15. However, the comprehensive care plan contained no activities focus, goal, or interventions. The AD stated an Activity Care Plan should have been developed.
Failure to Implement Foley Catheter Care Plan: A resident with a Foley catheter, prostate cancer, BPH, and UTI had a care plan calling for catheter care twice daily, infection monitoring, and urine assessment, but staff did not implement the planned interventions. The resident reported the urinary bag had not been emptied that morning, the catheter had not been replaced since admission, and the insertion site was not being cleansed routinely; a family member said they were providing the resident’s cleaning needs because staff care was inconsistent. The medical record lacked evidence of physician care orders being entered or routine Foley care being documented, and the DON confirmed the care plan interventions were not implemented because the orders were not in the chart.
Failure to Care Plan for Camera Monitoring Device: A resident with acute respiratory failure with hypoxia, cognitive changes following CVA, and chronic pain syndrome had a camera installed in the room at family request, with the device actively recording audio and video and a roommate present. The DON confirmed the family continuously monitored the feed, but the resident's care plan did not include the electronic communication device, despite an earlier care conference about the monitoring device and a posted sign indicating recording was in use.
The facility did not develop individualized, person-centered care plans for residents with Foley catheters, bowel and bladder retraining needs, and pain management requirements. For example, a resident with a Foley catheter had a care plan lacking specific details about the catheter and its care, while two residents needing bowel and bladder retraining had care plans without measurable objectives or tailored interventions. Additionally, a resident with chronic pain did not have all pain management interventions, including non-pharmacological methods, documented in the care plan.
A resident with a recent psychiatric hospitalization and new diagnosis of PTSD did not have a comprehensive care plan developed or implemented to address their updated mental health needs. The facility failed to conduct or document a PASRR Level 2 evaluation after the resident's acute change in condition, and the resulting recommendations for specialized services were not incorporated into the medical record or care planning process.
A resident with nicotine dependence and on oxygen therapy repeatedly expressed intent to continue smoking and was observed attempting to smoke, but staff did not develop a care plan to address these behaviors. This omission led to an incident where the resident's wheelchair caught fire, resulting in burns, as no interventions or monitoring were in place to manage the risk.
A resident receiving hospice services for a large, tunneling breast mass did not have a care plan in the facility's records addressing wound care, despite hospice providing this care. Facility staff confirmed the absence of a wound care order and care plan, which was not in accordance with facility policy requiring comprehensive, integrated care planning.
The facility did not create or implement comprehensive care plans for two residents with contractures and five residents receiving psychotropic medications. Observations and record reviews showed that contracture management, splint use, and interventions to prevent further loss of range of motion were not addressed in care plans. Similarly, care plans for residents on psychotropic medications lacked documentation of psychiatric diagnoses and medication management, despite facility policy requirements. Staff interviews confirmed these omissions.
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