Failure to Follow Care Plan for Pressure Ulcer Prevention
Summary
The facility failed to adhere to the care plan for a resident, identified as R145, who was at risk for pressure ulcers. R145 was admitted with multiple diagnoses, including encephalopathy due to subdural hematoma, chronic kidney disease, and cerebrovascular accident with hemiplegia. The resident was cognitively impaired and dependent on staff for all activities of daily living. The care plan for R145, dated 11/29/2023, included interventions for daily skin assessments, keeping the skin dry, and monitoring nutrition. However, the facility did not follow through with these interventions, as evidenced by the lack of documented skin assessments after 2/16/2024, despite a physician's order for weekly skin assessments. On 2/16/2024, a CNA reported an open area on R145's sacrum to an LPN, but there was no documented follow-up or additional skin assessments recorded in the medical record. The facility's failure to document and address the skin condition led to the development of an unstageable wound on the sacrum, which was identified by a Wound Nurse Practitioner on 3/27/2024. This oversight in care and documentation was a significant deviation from the facility's policy on comprehensive, person-centered care plans, which should include measurable objectives and timetables to meet the resident's needs. Interviews with facility staff revealed a lack of adherence to the care plan and communication breakdowns. The Corporate Wound Nurse indicated that CNAs are responsible for examining the skin during bathing and reporting changes to the unit nurse, while the MDS Coordinator emphasized the importance of following care plan interventions. Despite these protocols, the facility's staff did not consistently perform or document the required skin assessments, contributing to the resident's deteriorating condition.
Removal Plan
- R145 was discharged from the facility to the hospital for a septic wound and did not return to the facility.
- An AD-HOC meeting was held with the Administrator, Director of Nursing, Regional Director of Operations, Regional Director of Clinical Operations, and Chief Medical Officer to address the concerns identified related to the Immediate Jeopardy Citations.
- The RDO, RDCO, and CMO reviewed the center policy on Developing a Comprehensive Care Plan. No policy changes or recommendations were made because of this review.
- A Root Cause Analysis of the wound management system breakdown was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of analysis was put on the RCA Tool and was included in the Ad Hoc Quality Assurance Performance Improvement QAPI meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit.
- All residents had a pressure ulcer risk assessment performed. Care plans were reviewed and updated by the MDS Coordinators for 139 of 140 residents to ensure that the weekly skin check was listed as an intervention under the at-risk skin care plan.
- The center MDS Coordinator, Wound Care Nurse, and Regional Wound Care Specialist conducted an audit for 5 of 5 residents with pressure ulcers/injuries to ensure that all residents have a comprehensive wound care plan that is being implemented.
- Nursing employees, 6 of 7 RN's, 27 of 29 LPN's and 43 of 46 CNA's were educated by the RWCS, Staff Development Coordinator, and DON on implementation of the care plan for pressure ulcer prevention and management including location of the care plan in the electronic health record and viewing the care plan prior to the start of the shift. LPNs were educated regarding following physicians orders and the person-centered care plan. Any staff not educated during the initial education will have the education prior to the start of their shift or during the orientation period.
- Review of the root cause analysis showed LPNs and CNAs were educated to ensure weekly skin assessments will be completed on a weekly basis and documented. DON will ensure the completion of assessments in a timely manner. The DON verified the DON in-serviced staff along with RN PP. The DON stated CNAs were re-educated on how to fill out shower sheets (and give a copy to the charge nurse and DON), as soon as a skin condition was identified and to notify the nurse immediately.
- Review of a Daily Census revealed 139 of 140 residents were reassessed for risk for pressure ulcers and that residents had a care plan to include weekly skin assessments. This was verified by review of the pressure ulcer risk assessments and care plans for R12, R395, R400, R402 and R403.
- Review of the pressure Ulcer/Injury Care Plan Update Tool revealed 5 of 5 residents care plans were reviewed for accuracy of wound location and care plan reflective of care provided. Review of five residents, R12, R395, R400, R402 and R403, showed the residents had comprehensive care plans for pressure ulcers.
- Review of in-service sign in sheets revealed 27 of 29 LPNs, 43 of 46 CNA's and 6 of 7 RN's were in-serviced by the RWCS on care plans for pressure ulcer prevention and management.
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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