The facility failed to fully develop person-centered care plans for three residents. One resident receiving antipsychotic and antidepressant medications had care plans that did not include the measurable side effects staff needed to monitor, another resident with aphasia had no care plan intervention for a communication board despite staff confirming its use, and a third resident’s documented preference to keep the room door closed was not followed during observation.
A resident’s care plan was not updated to reflect her role as Resident Council President, and another resident’s fall interventions were not followed as written. Staff observed the fall mat on the wrong side of the bed, no "Call don't fall" sign in the room, and an LPN confirmed the ordered setup was not in place; the same LPN also confirmed the resident was not wearing hip protectors.
A resident with a care plan restricting blood pressure measurements and lab sticks in the left arm due to a mastectomy had blood pressures repeatedly taken from the restricted arm on several occasions, despite clear instructions in the care plan. The DON confirmed this should not have occurred.
A resident with a history of Alzheimer's disease and resistance to care began frequently refusing multiple prescribed medications shortly after admission. The care plan documented the resident's resistance but failed to include measurable goals or interventions to address the medication refusals. The DON confirmed the care plan was not completed in a timely manner.
Three residents with care plans or orders for bed rails to assist with mobility, transfers, or repositioning were observed without the required side rails in place. The DON confirmed that the bed rails were not present as specified in the care plans or orders.
A resident with a recent history of falls, persistent disorientation, chairbound status, predisposing diseases, and medications increasing fall risk was admitted and assessed as high fall risk. Despite these factors and a subsequent fall, the care plan did not include fall risk interventions until after the incident. The DON confirmed the omission of fall risk in the care plan prior to the fall.
A resident who was totally dependent on staff for eating did not have their need for feeding assistance consistently documented over several weeks, as required by their care plan. Additionally, interventions for impaired skin integrity, including floating heels and a turn/reposition schedule, were not implemented until after a deep tissue injury was identified. The DON confirmed these deficiencies in care plan implementation.
Three residents did not have their care plans updated to reflect their documented preferences for activities such as music, pets, and religious or spiritual activities, nor did one resident's care plan address a significant dental issue despite a dentist's recommendation and the resident's report of pain. These omissions were confirmed by facility staff during the survey.
A resident was observed with fall prevention interventions, including a fall mat and bed positioning, but these measures were not documented in the care plan and lacked physician orders. Staff confirmed the interventions were in use, but the required comprehensive care plan for fall prevention was not developed.
A deficiency was cited when a resident's care plan did not include all required elements, such as measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's care.
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