Failure to Update Care Plan After Resident Falls
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not ensure that the resident's bed was in the lowest position as per the care plan while the resident was in bed. Additionally, the facility did not update the resident's care plan with new interventions after the resident experienced three falls, which placed the resident and other fall-risk residents at risk of serious harm and injury. The resident involved was a male with Fragile X syndrome, muscle weakness, unspecified falls, lack of coordination, and cognitive communication deficit. He had a BIMS score of 0, indicating severe cognitive impairment, and required total assistance for sit-to-stand and bed transfers. Despite being at high risk for falls, as indicated by multiple fall risk evaluations, the facility did not update the resident's care plan with new interventions following his falls, which included injuries such as a hematoma and skin tears. Interviews with facility staff revealed a lack of communication and responsibility regarding updating the resident's care plan. The MDS nurse responsible for the resident's care plan had recently quit, and there was confusion among staff about who should update the care plan. Despite discussions in morning meetings about the resident's falls, the care plan was not updated, and staff were not informed of new interventions. This lack of action and communication contributed to the deficiency identified by surveyors.
Removal Plan
- Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of the findings with no new orders received.
- Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders were received.
- The IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified.
- The Director of Nursing and/ or designee reassessed residents who sustained falls head to toe for pain and injury with no new concerns.
- The Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns for appropriate treatment, care plan interventions and resolutions.
- The Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated.
- The IDT reviewed the falls care plans for residents identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. There were updates completed as indicated.
- The Director of Nursing and/ or designee reviewed the progress notes to ensure resident falls and/ or changes in condition related to falls were identified and addressed. There were no concerns noted.
- The Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions.
- The Director of Nursing and/ or designee reviewed the care plans for current residents who sustained falls for implementation of interventions to address the fall. Where applicable the care plans were modified for individualization.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls.
- The Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy.
- The Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status.
- The Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions.
- The Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift.
- The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk.
- An Ad Hoc QAPI was conducted attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 656- Develop/Implement Comprehensive Care Plan.
- The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months. Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Include Bipolar Disorder and Anxiety in Care Plan: A resident with bipolar disorder, anxiety, depression, and dementia had psychiatry notes documenting ongoing symptoms and medication management, but the care plan did not include focus areas for bipolar disorder or anxiety. The MDS coordinator confirmed these diagnoses were not included in the care plan.
Missing behavior and side effect monitoring for psychotropic medications: A resident with dementia, psychotic disorder, anxiety, and depression, another resident with traumatic brain injury and schizoaffective disorder, and a third resident receiving multiple psychotropics had no documented behavior monitoring or side effect assessments to support ongoing use of the medications. Staff confirmed missing monitoring orders and records, and the DON could not provide documentation showing routine monitoring of behaviors, symptoms, or AIMS follow-up after dose increases.
Failure to care plan an external catheter urinary wicking system: A resident with anxiety, chronic pain, scoliosis, and end stage HF was admitted cognitively intact but dependent for toileting and personal hygiene and always incontinent. His care plan addressed incontinence care, but it did not include the external catheter system, who would reapply it, or when the collection canister would be emptied. The resident said he needed help with setup and reapplication, urine containers were observed on the floor with one full of dark yellow urine, and the DON stated the system should have been addressed on the care plan.
Incomplete and Outdated Person-Centered Care Plans: A resident’s care plan did not include full code status even though the chart and orders documented full code, and another resident’s care plan was not revised after recent behaviors led to a psych assessment documenting instability and directing redirection. The records showed significant medical and cognitive diagnoses, but the care plans did not fully reflect the residents’ current needs and status.
The facility failed to develop and implement complete care plans for two residents. One resident on dialysis had a care plan for ordered diet and meal intake monitoring, but multiple meal percentages were not documented after dialysis meals. Another resident with a suprapubic catheter was observed with an exposed, uncapped attachment nozzle, and the care plan did not include the resident’s self-care of the catheter. Staff and the DON confirmed the resident ate after dialysis and that the catheter tip should be covered when switched.
Care Plan Lacked Dialysis-Specific Information: A resident with acute kidney failure and renal failure was receiving hemodialysis 3 days per week, but the care plan did not include a dialysis-specific focus, goal, or interventions. RN and DON both confirmed the plan lacked basic details such as the nephrologist, dialysis location, access site care and monitoring, and the dialysis schedule.
Failure to Include Bipolar Disorder and Anxiety in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #11, who was reviewed for unnecessary medications. Review of the resident’s psychiatry note dated 04/29/26 documented diagnoses of bipolar disorder and other anxiety disorder, with the note stating that the resident had chronic episodes of depression and manic-like symptoms causing distress and functional impairment, and that mood stabilizer medication needed to be continued long term. A later psychiatry note dated 07/29/26 documented a past psychiatric history of bipolar disorder, depression, anxiety, and dementia, and stated that trazodone and Prozac were managing depression, donepezil was helping dementia, lamotrigine was assisting with bipolar disorder, and clonazepam was assisting with anxiety. Review of Resident #11’s care plan showed that it did not include a focus area for bipolar disorder or anxiety disorder. During interview on 08/12/26 at 1:25 PM, the Corporate MDS Coordinator stated that anxiety disorder and bipolar disorder were not included in the resident’s care plan and would be added. The facility’s policy on care plans stated that the comprehensive, person-centered care plan will describe the services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Missing behavior and side effect monitoring for psychotropic medications
Penalty
Summary
The facility failed to ensure adequate monitoring for behaviors and side effects was documented for 3 of 6 residents reviewed. Resident #1 was admitted with diagnoses including dementia, seizure disorder, psychotic disorder, anxiety disorder, and depression, and had physician orders for multiple psychotropic medications, including olanzapine, haloperidol, and Ativan. No orders were found directing staff to monitor the resident for behaviors or side effects related to these medications. During review, staff confirmed that no such monitoring orders were present in the MAR or TAR, and the DON stated that behavioral and side effect monitoring orders had not been restarted after the resident returned from the hospital. Resident #11 was admitted with diagnoses including traumatic brain injury, schizoaffective disorder-bipolar type, major depressive disorder, and paraplegia, and had orders for Haldol, olanzapine, and divalproex sodium. The record did not contain an order for behavior monitoring or assessment of antipsychotic side effects, and there was no behavior monitoring flow record in the EMR. Although an AIMS assessment had been completed on 3/29/26 showing no abnormal movements, Haldol and divalproex doses were increased in May 2026 without a follow-up AIMS assessment for the dose changes or the scheduled quarterly assessment in June 2026. Resident #4 had orders for paroxetine, trazodone, divalproex, and risperidone, but the clinical record, including nursing documentation and behavior monitoring records, contained no documented behaviors, symptoms, frequency, severity, or other clinical indicators showing the continued need for the psychotropic medications. The DON was unable to provide documentation showing the resident's behaviors or symptoms were routinely monitored to evaluate effectiveness and continued clinical need, despite facility policy requiring behavior and side effect monitoring every shift using the electronic Behavior Monitoring Flow Record.
Failure to Care Plan External Catheter Urinary Wicking System
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was admitted with anxiety disorder, chronic pain syndrome, scoliosis, and end stage heart failure. The resident’s admission MDS, dated 06/08/2026, indicated a BIMS score of 13, that he was cognitively intact with little to no impairment, dependent on staff for toileting and personal hygiene, and always incontinent. The comprehensive care plan printed 08/10/2026 addressed bladder incontinence with interventions for incontinent care every 2 hours and moisture barrier application after each episode, but it did not include the resident’s external catheter urinary wicking system. The record did not identify who was responsible for reapplying the external catheter system, emptying the collection canister, or the frequency for those tasks. During interview and observation on 8/10/26, the resident stated he used the external catheter urinary wicking system, paid for the supplies himself, and needed assistance with setup and reapplication as needed. Two urine collection containers were observed on the floor next to the bed, and one was full of dark yellow urine. On 08/11/2026, the DON stated the hospice nurse applied the system weekly on Mondays, there were no orders or documentation for it being changed, and the system should have been addressed on the care plan to ensure care and services were provided on admission. During a later observation, the resident said the bag had been off since yesterday, then said it had just come off, and the DON and Regional Nurse applied the external catheter urinary wicking system after completing care.
Incomplete and Outdated Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, including measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. For one resident, the record showed admission with diagnoses including complete traumatic amputation of the right foot, diabetes II, and cognitive communications deficit, and the admission record and physician orders documented full code status. The resident’s MDS reflected a BIMS score of 13/15 and wheelchair use, but the care plan did not include the resident’s full code status. For another resident, the record showed diagnoses including pelvic fracture, major depressive disorder, Alzheimer’s disease, dementia, anxiety disorder, and psychotic disorder, with a quarterly MDS documenting a BIMS score of 00 and no behavioral symptoms. The care plan included a potential for physical aggression related to dementia/confusion and a note about antidepressant use related to depression, but nursing staff did not review and revise the comprehensive person-centered care plan after recent behaviors prompted a psychiatric assessment that documented the resident as unstable and directed use of redirection. The DON stated care plans should be updated with changes as they happen, new orders, and quarterly updates.
Incomplete care planning and documentation for dialysis nutrition and catheter self-care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #6 related to dialysis and meal intake documentation. Resident #6’s care plan, initiated on 5/21/2026, included interventions to provide and serve diet as ordered and to monitor intake and record it every meal. However, the Task ADL Eating and Meal Percentage record did not document meal intake percentages for 7/16/2026, 7/17/2026, 7/18/2026, 7/23/2026, 7/25/2026, 7/30/2026, 8/1/2026, 8/3/2026, 8/4/2026, and 8/6/2026. The physician order dated 5/20/2026 specified a renal diet, regular texture, regular/thin liquids, and a 1000 ml fluid restriction. Staff stated that after dialysis the resident returned to the facility for lunch and that meal intake should be recorded in PointClickCare, and the DON stated the resident normally received a chef salad or new tray after dialysis and that staff should record what was given and what was eaten. The facility also failed to include Resident #18’s self-care of a suprapubic catheter in the care plan initiated on 06/07/2026. During observation on 08/09/2026, the resident’s Foley bag was hanging from the bedside frame and the attachment nozzle was exposed and lying on the bed. Staff stated the resident switches to the leg bag himself and that the tip should be covered. The resident stated he wears the larger bag at night and puts the leg bag on in the morning himself, and the ADON/Infection Control Nurse stated that when a new leg bag is opened it comes with a blue cap and it needs to be covered when he switches it and leaves it on the bed. The MDS for 06/07/2026 documented an indwelling catheter Foley, and the physician order read suprapubic catheter care every shift.
Care Plan Lacked Dialysis-Specific Information
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident with kidney failure who was receiving hemodialysis. R1's admission MDS dated [DATE] indicated she was cognitively intact, required minimal to moderate assistance with activities of daily living, and had diagnoses of acute kidney failure and renal failure. R1's EMAR showed an order for dialysis every Tuesday, Thursday, and Saturday, but her care plan did not include a focus, goal, or intervention specific to dialysis. During interview, RN-A confirmed R1 received dialysis 3 days per week and stated the care plan did not contain information about R1's nephrologist, where she received dialysis treatments, or how to monitor or care for the dialysis site. RN-A stated she would expect basic information related to dialysis. The DON also confirmed the care plan lacked a focus, goal, and intervention for R1's dialysis treatment and stated she expected care plans for residents receiving dialysis to include information such as access site care and monitoring, nutritional guidelines or restrictions, and the dialysis schedule.
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