Failure to Revise Care Plan for Resident with Behavioral Issues
Summary
The facility failed to revise a comprehensive care plan for a resident known to exhibit behaviors of getting into bed with other residents. This failure resulted in staff not having access to preventative measures to deter such behavior. On one occasion, the resident was found in bed on top of another resident, who was unresponsive and later pronounced dead. This incident placed all residents at risk and was likely to cause serious injury, harm, impairment, or death. The care plan for the resident in question did not include revisions to address the behavior of getting into other residents' beds, despite previous incidents being documented. Staff interviews revealed that the care plan was not updated to reflect these behaviors, and no increased monitoring or interventions were put in place. The resident had a history of delusional, aggressive, and socially inappropriate behavior, and was severely cognitively impaired, which further necessitated the need for a revised care plan. Interviews with facility staff, including the Social Service worker and the Director of Nurses, confirmed that the care plan should have been updated to include one-on-one observation and increased monitoring. The failure to update the care plan and implement necessary interventions left other residents vulnerable to harm, as the resident was ambulatory and could have entered any resident's bed, posing a risk of accidental harm or abuse.
Removal Plan
- Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
- The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
- The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
- An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
- A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
- The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
- An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining one-on-one supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses were instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
- The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
- The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
- An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
- A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
- A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the MS State Department of Health.
- An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing one-on-one supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
- The Ombudsman was notified of the incident.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
IDT Did Not Review Quarterly Care Plan Revisions: A resident with anoxic brain damage, pulmonary HTN, and paraplegia had quarterly MDS assessments completed, but no IDT care conferences were documented for an extended period while the care plan was revised multiple times. Interviews showed the CQAN said the quarterly care planning process included an IDT meeting and that the IDT significantly influenced the care plan, while the MDS Coordinator said she completed quarterly reviews even when no IDT had been held.
Failure to Offer Quarterly Care Conferences: A resident with depression, anxiety, chronic pain, and DM was not consistently offered or documented for quarterly care conferences. The EMR showed one conference note where the resident declined participation, but no evidence of any later conferences being offered, provided, or refused. The resident said she did not always know the plan of care, and the family member said she had not been invited in over a year and did not know what was going on with the resident’s care.
A resident with chronic respiratory failure with hypoxia and diabetes had physician orders for continuous O2 and compression stockings, but was observed without either in place. The care plan did not document the oxygen or compression stocking interventions, and the DON stated refusals also were not documented.
A resident with major depressive disorder, stroke-related weakness/paralysis, and anxiety had a care plan that did not reflect her PASRR positive status for mental illness or include PASRR-related interventions, even though records showed she had been receiving MI specialized services and attending quarterly PASRR meetings. The annual MDS was coded as no ID/DD-related PASRR condition, and staff including the MDS coordinators, DON, and Administrator acknowledged the care plan was inaccurate and should have been reviewed and revised by the IDT.
Care plan not updated for new insulin use and blood sugar monitoring. A resident with DM and intact cognition began receiving insulin and required BG monitoring, but the care plan did not reflect the new insulin regimen or monitoring needs. The MAR showed insulin orders, and a progress note documented BG checks before lunch and dinner. Staff stated the resident was a new diabetic and the care plan had not been updated to match the new diagnosis.
A resident’s CCP was not updated after an oxygen order changed from 3 LPM to 4-5 LPM, and two other residents’ CCPs did not reflect self-administration of medications. One resident with schizophrenia had multiple meds ordered for bedside storage or unsupervised self-administration, but the CCP had no related focus or interventions. Another resident with dementia and diabetes was observed self-administering insulin even though the CCP only addressed staff administration.
IDT Did Not Review Quarterly Care Plan Revisions
Penalty
Summary
The facility failed to ensure Resident #40’s comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after quarterly assessments. Resident #40 was admitted with diagnoses including anoxic brain damage, pulmonary hypertension, and paraplegia. The record showed an IDT care conference was completed in January 2026, and the resident later had a Significant Change Assessment on 2/2/26 and Quarterly Assessments on 3/9/26 and 6/7/26, but no other IDT care conferences were documented until 8/13/26. The resident’s care plan was revised multiple times between January 2026 and 8/13/26, including revisions on 2/12/26, 2/17/26, 2/22/26, 2/23/26, 2/25/26, 3/25/26, 4/6/26, 4/15/26, 4/21/26, 5/4/26, 5/13/26, 6/9/26, 7/30/26, 8/7/26, and 8/10/26. During interviews, the CQAN stated the quarterly care planning process included an IDT meeting and that the IDT significantly influenced the information incorporated into the quarterly care plan, while the MDS Coordinator stated she completed quarterly care plan reviews regardless of whether an IDT had been held. The facility policy stated comprehensive, person-centered care plans are based on resident assessments and developed by an IDT.
Failure to Offer Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure quarterly care conferences were provided or offered for one resident who was cognitively intact and did not exhibit rejection of care behavior. The resident’s quarterly MDS indicated diagnoses of major depressive disorder, anxiety, chronic pain, and diabetes. A progress note from 5/21/25 documented that a conference occurred without the resident or a resident representative in attendance, and the resident stated she did not want to participate. The EMR did not contain evidence that any other care conference was offered, provided, or refused after that date. During interviews, the resident stated she did not always know what the plan was and could not remember attending or being offered a care conference in a long time. The social worker verified that no care conferences were documented in the EMR since May 2025 and stated care conferences should be completed quarterly. The social worker also stated the resident was due for conferences in March and June 2026 and that the family member would have been invited. The family member stated she had not been invited to or attended a care conference in over a year and did not know what was going on with the resident’s care. The DON stated quarterly care conferences were expected and that if the resident declined to participate, the EMR would have evidence of the refusal. Facility policy required residents and their representatives to be invited at least two weeks in advance, and if not invited, an explanation had to be included in the medical record.
Care Plan Not Updated for Oxygen and Compression Stocking Needs
Penalty
Summary
The facility failed to ensure a resident’s care plan was revised to reflect current needs and interventions. The facility’s policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and that care plans are revised as resident information and conditions change. Resident #55 was admitted with multiple diagnoses including chronic respiratory failure with hypoxia and diabetes, and had physician orders for compression stockings to the right leg and continuous oxygen at 1-2 L/min via nasal cannula as tolerated. On 8/4/26, Resident #55 was observed in her room with a portable liquid oxygen unit on the back of her wheelchair and an oxygen concentrator at bedside, but she was not wearing oxygen or compression stockings. CNA #2 stated the resident did not have oxygen on and should have. Review of the resident’s care plan showed it did not document the use of oxygen or compression stockings. The DON stated the care plan had not documented the use of oxygen or compression stockings and should have, and that refusals should have been documented but were not.
Care plan not updated for PASRR-positive resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one resident with PASRR positive status for mental illness. Resident #2 was admitted and readmitted with diagnoses including major depressive disorder, stroke with hemiplegia and hemiparesis, and anxiety disorder. Her annual MDS dated 03/13/2026 showed a BIMS score of 10, indicating moderate cognitive impairment, and the MDS Section A1500 was coded as no ID/DD-related PASRR condition. However, record review showed she had been PASRR positive for mental illness since a Level 1 screening dated 07/24/2025 and had a PASRR Comprehensive Service Plan dated 08/27/2025 showing she received MI specialized services. The resident’s care plan updated on 07/08/2026 addressed antipsychotic medication use for major depressive disorder with monitoring and reporting interventions, but no care plan identified her PASRR positive status or included interventions related to PASRR services. During interviews, the resident and family stated she had been PASRR positive since admission, attended quarterly PASRR meetings, and received MI specialized services. MDS Coordinator A, MDS Coordinator B, the DON, and the Administrator all stated the care plan should reflect PASRR positive status and be reviewed and revised by the IDT, and they acknowledged the annual MDS and comprehensive care plan were not accurate.
Care plan not updated for new insulin use and blood sugar monitoring
Penalty
Summary
The facility failed to update the care plan for R36 when the resident began using insulin and required blood sugar monitoring. R36 had a diagnosis of diabetes mellitus, and the Quarterly MDS documented a BIMS score of 15, indicating intact cognition, with no insulin use listed on the medication list at that time. The Annual MDS later documented that R36 received seven days of insulin, but the care plan dated 06/27/2026 did not include information that the resident had started insulin or needed blood glucose monitoring. The MAR dated 06/28/2026 showed insulin orders for 10 units subcutaneously at bedtime with blood glucose checks and 14 units subcutaneously in the morning, and a progress note dated 07/16/2026 documented that blood sugar was to be checked before lunch and dinner. Administrative Nurse E stated that R36 was a new diabetic and the care plan had not been updated, and Administrative Nurse D stated that care plans should be updated when a resident has a new diagnosis. The facility policy on care plan revisions upon status change stated that the process was intended to provide a consistent review and revision of the care plan for residents experiencing a status change.
CCPs Not Updated for Oxygen Orders and Self-Administration Needs
Penalty
Summary
The facility failed to keep the Comprehensive Care Plan (CCP) updated for a resident with malignant neoplasm of the left bronchus or lung, chronic obstructive pulmonary disease, and chronic respiratory failure. The resident’s CCP still listed oxygen at 3 liters per minute via nasal cannula with a start date of 10/23/2025, while the active physician’s order reviewed on 7/21/2026 directed continuous oxygen via nasal cannula at 4 to 5 liters, with a start date of 5/23/2026. The Clinical Nurse Manager confirmed on 8/3/2026 that the CCP had not been updated when the oxygen order changed and should have been. The facility also failed to include self-administration of medications in the CCPs for two residents. One resident with schizophrenia had active orders for several medications that could be kept at bedside or were marked for unsupervised self-administration, including cough drops, Vicks VapoRub, saline mist, and Abreva, and was observed with cough drops on the bedside table while stating the medication could be kept in the room. The CCP contained no focus, goal, or interventions related to self-administration, and the CNM confirmed this omission. Another resident with unspecified dementia and type 2 diabetes mellitus had an order for insulin lispro injections, no order for self-administration, and a CCP that addressed insulin-dependent diabetes only with medication administration by staff; however, the resident was observed being handed an alcohol wipe and syringe and then self-administering insulin.
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