A resident with COPD was receiving hospice services, but the care plan did not include hospice interventions. The quarterly assessment documented hospice, and both the DON and administrator confirmed the care plan lacked hospice-related interventions.
The facility failed to develop and update comprehensive care plans for two residents with significant clinical needs. One resident admitted with DM2 and acute kidney injury had a care plan that did not include these diagnoses, despite later being found unresponsive and critically ill with severe hypoglycemia and hypotension, and having acute kidney failure and diabetes documented on the death certificate. Another resident with severe cognitive impairment, severe protein-calorie malnutrition, and notable weight loss had a nutrition therapy assessment and MD orders for weekly weights and specific nutritional interventions, but these were not incorporated into the care plan. The MDS coordinator and DON acknowledged that these conditions and interventions should have been reflected in the residents’ plans of care.
A resident did not have a required comprehensive care plan completed within the timeframe specified by facility policy following completion of the admission MDS assessment. Record review showed that although the admission assessment was completed, no comprehensive care plan was present in the EMR, and only an undated baseline care plan was available. In interviews, the MDS coordinator acknowledged that a comprehensive care plan had not been developed for the resident, and the administrator confirmed that only the baseline care plan could be found and that they were aware the comprehensive care plan was not done.
A resident with dementia and depression, who was moderately cognitively impaired, frequently refused showers, became agitated or aggressive when asked to bathe or get out of bed, and sometimes would not allow staff to change incontinence briefs, as reported by multiple CNAs and an LPN. Staff documented these refusals and behaviors in progress notes and behavior notes, including an episode of aggression related to showering, but no ongoing interventions or preventive strategies were identified in the behavior documentation. The resident’s comprehensive care plan did not include interventions for these behavioral symptoms or shower refusals, despite the pattern of behavior and staff awareness, and the MDS coordinator acknowledged that these behaviors should have been included in the care plan.
Two residents who were identified smokers did not have comprehensive smoking care plans reflecting their needs and behaviors. One resident’s admission assessment documented smoking and the resident reported needing someone to stay with them while smoking due to use of a transport wheelchair, yet the initial care plan omitted any smoking concern and a smoking care plan with interventions was only added later. Another resident, observed smoking outside and documented as able to smoke with minimal supervision and having signed the facility’s smoking policy, also lacked a smoking-related care plan. The DON acknowledged responsibility for overseeing the MDS coordinator and confirmed both residents had been smokers since admission without appropriate smoking care plans in place.
Surveyors determined that the facility failed to include a leg contracture in the comprehensive, person-centered care plan for a resident with a history of stroke, osteoarthritis, and aseptic necrosis of the femur. The resident’s left leg was observed to be contracted, and the resident reported using a compression sleeve for comfort and needing pain medication. The existing care plan addressed assistance with lower body dressing and the need for a total lift for transfers but did not address the contracture. A CNA and an RN confirmed the contracture was not on the care plan they used to guide care, and both the MDS coordinator and DON acknowledged that the contracture should have been included.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for several residents. One resident with left-sided weakness and a contracted hand had no care plan problem for limited ROM, no therapeutic devices, and no restorative or ROM interventions, despite staff recognizing the impairment. Another resident with protein-calorie malnutrition and significant documented weight loss had a care plan requiring meal replacement supplements when eating 50% or less of meals, but staff did not provide the ordered health shakes, and the resident reported not receiving supplements. A third resident, dependent for transfers and using a mechanical lift as confirmed by staff and observation, did not have lift use included in the care plan, even though the MDS coordinator stated such interventions should be documented.
A resident was admitted and remained in the facility long enough to require a comprehensive, person-centered care plan per facility policy, but no such care plan was ever developed or documented in the EMR. The facility’s policy required completion of a comprehensive care plan within a set timeframe following the MDS admission assessment, yet both the MDS coordinator and the DON confirmed they could not locate any comprehensive care plan for this resident and acknowledged that it should have been completed within 14 days of the comprehensive assessment.
A resident with malnutrition, GI hemorrhage, dysphagia, and a feeding tube experienced significant weight loss over about one month, but the care plan was not updated to reflect this change or add specific interventions. The existing care plan only noted the need for tube feeding and periodic RD evaluation, despite physician orders for multiple daily bolus feedings of Jevity 1.5. During interviews, an LPN reported the resident received five bolus feedings daily for a few days, and the MDS coordinator acknowledged that the care plan should have documented the greater than 5% monthly weight loss and included measures to prevent further loss.
A resident with severe cognitive impairment, obstructive uropathy, and a suprapubic catheter was admitted with physician orders for catheter changes as needed, output monitoring each shift, and catheter care every shift, and treatment records showed catheter care was being provided. However, the comprehensive care plan created after admission addressed only activities and did not include any focus, goals, or interventions for catheter care or ADLs, despite the resident’s dependence for transfers and need for assistance with self-care. A resident representative confirmed the catheter was present throughout the stay, a CNA reported there was no documentation directing catheter care, and both the DON and MDS coordinator later acknowledged that the comprehensive care plan was incomplete and had been missed.
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