Care plans were not revised after significant changes for four residents. One resident with PTSD and trauma history had no documented trigger assessment or inclusion of psychiatric counseling recommendations in the care plan. Another resident had significant weight loss, but the care plan remained contradictory and no significant change assessment was found. A resident with an unwitnessed fall and head bruise had no new fall-prevention interventions added, and another resident’s care plan was not updated after a diet order changed from thickened to thin liquids.
Surveyors found that the facility did not revise a resident’s oral/dental care plan after all teeth were extracted, leaving the plan to reference natural teeth in poor repair despite the change in condition. In addition, another resident reported never being involved in a care plan meeting since admission, while the MDS coordinator stated the resident declined participation but could not provide documentation of this refusal. These issues demonstrate failures to update care plans after significant changes and to document resident choice regarding participation in care planning.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident's care plan was not revised to address a toothache that had been present for an extended period. During record review and resident interview, the issue was identified as ongoing, and the DON confirmed that it had not been included in the care plan.
A resident exhibited repeated behavioral issues, including entering other residents' rooms, consuming their food and drinks, and public urination, which were observed and documented by staff. Despite these ongoing behaviors and the need for frequent redirection, the care plan was not updated to reflect or address these concerns.
A resident's care plan was not updated to include all current fall interventions, such as 1:1 supervision, floor mats, and bed placement, despite these measures being in place and ordered. The care plan only listed a low bed with a parameter mattress, and omissions were confirmed by the DON and a corporate RN.
A resident's care plan was not revised to include the correct diagnosis of restless leg syndrome and instead incorrectly listed Parkinson's disease. This error was identified during a record review and confirmed by the facility administrator.
A resident repeatedly engaged in sexually inappropriate behaviors toward female residents, including entering their rooms without permission and making inappropriate comments. Despite ongoing documentation of these incidents by staff and social services, the care plan was not updated to include new interventions, and the facility did not report the incidents as abuse or take adequate steps to prevent recurrence.
A resident's care plan was not revised after an antidepressant (Celexa) was discontinued, and the care plan also incorrectly listed a diagnosis of Parkinson's Disease, which the resident did not have. These issues were confirmed by the DON during a record review.
The facility did not include residents, responsible parties, or the full interdisciplinary team in care plan meetings, and failed to update care plans when new medications were added. Two residents with intact cognition were unaware of their care plans, and documentation lacked evidence of proper meeting attendance or resident involvement.
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