Failure to Implement Comprehensive Care Plan Leads to Resident's Death
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with dysphagia, which ultimately led to the resident's death by choking on a sandwich. The resident, a male with a complex medical history including cerebral palsy, functional quadriplegia, and dysphagia, required total dependence on all activities of daily living and had been prescribed one-to-one assistance during meals to prevent choking or aspiration. Despite these requirements, the resident was left unsupervised with a meal for 32 minutes, during which time he choked on a sandwich and was later found unresponsive. The resident's care plan did not include the necessary intervention of one-to-one assistance while eating, despite the speech therapy evaluation and physician orders indicating the need for such supervision. The facility's failure to customize the care plan to address the resident's specific needs for meal supervision was a critical oversight. Additionally, the facility's MDS nurse did not include the dysphagia diagnosis in the resident's chart and care plan, which contributed to the lack of appropriate supervision during meals. Interviews with facility staff revealed a lack of clarity and accountability regarding the auditing of care plans and the inclusion of therapy diagnoses. The Director of Nursing acknowledged that audit processes were not perfect due to recent changes in ownership and leadership, while the MDS nurse admitted to not always entering therapy diagnoses with medical diagnoses. This lack of proper documentation and oversight resulted in the resident being left without the necessary supervision, leading to the tragic outcome.
Removal Plan
- The policy for comprehensive care plans was reviewed and/or revised by the Administrator and Regional Director of Clinical Operations without a recommendation for revisions.
- The MDS Nurse reviewed care plans for 45 of 45 in-house residents identified with a diagnosis of dysphagia. Thirty care plans were updated to include a diagnosis of dysphagia current and active care plans for dysphagia and appropriate levels of meal supervision.
- The DON in-serviced the MDS team and licensed nurses on the Center's Comprehensive Care Plan policy and development/implementation and adherence of care plans. (RNs nine of nine equaling 100%; LPNs 42 of 43 equaling 97.7%; OVERALL 98%).
- Employees on leave of absence, vacation, agency staff, or new hires will be re-educated by the Staff Development Coordinator, DON, or Nursing Supervisor prior to returning to duty, and will not be given an assignment until they are given additional on-site education.
- The DON and Regional Director of Clinical Operations reviewed residents in the past thirty days with a new diagnosis of dysphagia to ensure that care plans were updated as appropriate.
- The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a documented history of depression was prescribed Buspirone and Vistaril for anxiety, and the MDS reflected use of anti-anxiety medications, yet the Active Diagnoses section did not list an anxiety disorder. Review of the resident's care plans showed they addressed only depression and antidepressant use, and the psychotropic medication care plan referenced only antidepressants, omitting the anti-anxiety drugs. The MAR confirmed ongoing administration of both anti-anxiety medications, and the DON acknowledged that the resident's anxiety and related medications were not included in the active care plans.
A resident with multiple diagnoses, including type 2 DM, depression, mood disorders, and osteomyelitis, and with moderately impaired cognition, was receiving continuous supplemental O2 per a physician order specifying 2–3 L/min via nasal cannula on day and night shifts to maintain O2 saturation above 90%. Despite this ongoing O2 therapy, the resident’s comprehensive care plan, last revised shortly before the O2 order, contained no problem, goals, or interventions related to supplemental oxygen or its use. The Corporate DON confirmed that no care plan had been developed to address the resident’s supplemental O2 needs, resulting in a deficiency under the comprehensive care plan requirements.
A resident with paroxysmal atrial fibrillation, encephalopathy, severely impaired cognition, and documented moderate hearing difficulty with hearing aids did not have a care plan addressing hearing loss or hearing aid use. Review of the care plan showed no problem focus or interventions for hearing aid care or storage, despite MDS assessments indicating hearing needs. Staff confirmed there was no care plan for hearing loss, and the Administrator reported the resident’s hearing aids had been lost and later reordered. Facility policy required the IDT to periodically review and revise care plans based on resident needs, but this was not done for the resident’s hearing and hearing aid management.
Two cognitively intact residents with documented pressure ulcers on admission, including an unstageable ulcer that later progressed to stage II and a sacral pressure injury, did not have any corresponding pressure-ulcer care plans or interventions in their records. Review of progress notes and skin evaluations confirmed the presence of these wounds, while care plan review showed no entries addressing them. In an interview, the MDS coordinator and the DON acknowledged that the care plans did not include the residents’ pressure ulcers, despite facility policy requiring comprehensive care plans to be developed following resident assessments.
A resident with cognitive impairment and multiple comorbidities had recurrent redness and rash under the breasts, in the groin, and other skin folds documented repeatedly on shower sheets over an extended period, with notes that the condition had worsened and been present for months. A Wound NP later assessed the resident and diagnosed extensive fungal dermatitis with detailed measurements of affected areas. Despite this ongoing skin impairment and the facility policy requiring a comprehensive person-centered care plan with measurable objectives and timetables, no such care plan or documented interventions specific to the rash were found in the medical record, as confirmed by the MDS nurse.
A resident with multiple chronic conditions, including dementia and Parkinson’s disease, was initially assessed as low risk for wandering but later scored as moderate and then high risk on wander-risk evaluations. Despite these increasing risk scores, the sections of the wander-risk tools designated for care plan interventions were left blank, and no elopement-risk care plan was initiated. The resident began self-propelling in a wheelchair and ultimately exited through an emergency exit door, triggering an alarm and sustaining an unwitnessed fall outside before being promptly found and assessed by staff. Interviews showed that an LPN completing the assessments had never filled out the intervention section, the MDS/RN relied on IDT judgment and did not care plan solely for wandering behavior, and leadership acknowledged that a care plan should have been implemented earlier in accordance with facility policy requiring care plan revisions when resident conditions change.
Failure to Care Plan for Anxiety Disorder and Anti-Anxiety Medications
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's anxiety disorder and related anti-anxiety medications, as required by §483.21(b). The resident was admitted with a diagnosis of depression and later received new physician orders for Buspirone 5 mg twice daily and Vistaril 25 mg three times daily, both prescribed for anxiety. The quarterly MDS assessment documented that the resident received anti-anxiety medication during the assessment period, but the Active Diagnoses section did not list an anxiety disorder diagnosis despite the ongoing use of two medications for that condition. Review of the resident's active care plans showed no care plan specifically addressing anxiety or the use of anti-anxiety medications. Existing care plans addressed potential mood fluctuations and depression, focusing only on antidepressant use, and a separate care plan for risk of adverse reactions to psychotropic medications referenced only antidepressant therapy for depression. The MAR confirmed that the resident was receiving Buspirone and Vistaril as ordered for anxiety. In an interview, the DON confirmed that the resident's active care plans did not address her anxiety or the use of anti-anxiety medications and acknowledged that a care plan for anxiety should have been in place.
Plan Of Correction
1. Resident #100 had their order for Buspar and Vistaril orders clarified on 4/22/26 by the Unit Manager to clarify the indication for use of the ordered medications and validated care plan for accuracy. The Buspar order was clarified by the physician to be used for diagnosis of Depression and the Vistaril order was clarified by the physician to be used for a diagnosis of itching. The care plan was updated to include the use of the antianxiety/anxiolytic medications for diagnoses of Depression and Itching on 5/7/26 by Social Service Designee. The resident does not have an active diagnosis of Anxiety as clarified by the physician. 2. Like Residents are identified as residents who utilize medication for anxiety. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Medication Review Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure residents who utilize medication for anxiety have an active diagnosis and care plan in place to address anxiety. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Care Planning and Physicians Orders Policies to ensure orders include an accurate and appropriate diagnosis and a care plan is initiated or revised to indicate use of antianxiety/anxiolytic medications. This education will be completed on or before 5/13/26. 4. Utilizing the Medication Review Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will F 0656 complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents who utilize medication for anxiety have an active diagnosis and care plan in place to address anxiety. Discrepancies noted from audits will be corrected to include clarification of orders and revision of care plans. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Care Plan for Resident Receiving Continuous Supplemental Oxygen
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing the use of supplemental oxygen for a resident who was receiving continuous oxygen therapy. The resident was admitted with diagnoses including type 2 diabetes mellitus, depression, mood disorders, and osteomyelitis, and had moderately impaired cognition per a recent MDS assessment. Review of the resident’s care plan, last revised on 03/07/26, showed no care plan interventions or goals related to supplemental oxygen or oxygen use, despite the resident’s ongoing need for this treatment. Further review of the medical record revealed a physician’s order dated 03/09/26 for oxygen at 2–3 L/min via nasal cannula, to be administered on day and night shifts to maintain oxygen saturation above 90%. This order demonstrated that the resident was to receive continuous supplemental oxygen, yet no corresponding care plan was developed to address this treatment and related care needs. During an interview, the Corporate DON confirmed that the facility did not create a care plan for the resident’s supplemental oxygen and oxygen use, verifying the absence of required care planning for this service.
Plan Of Correction
DON completed a physical head-to-toe assessment/observation of Resident #66 on 03/26/26. No negative effects were identified related to care plan issues identified during the Annual Survey. LNHA notified Resident #66's primary care provider on 03/26/2026 of missing documentation regarding care plan and notified there was no harm or negative effects to the resident regarding this lack of documentation. Primary care provider acknowledged the missing care plan documentation related to care required while using oxygen, and no harm or negative effects. No new orders currently. Resident #66 passed away (was on hospice - not related to oxygen use or misuse) and his care plan was not updated prior to his passing. On or before 04/30/2026, DON/Designee will educate licensed nursing personnel regarding the following: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.(iv) In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally-competent and trauma-informed. On or before 04/30/2026, DON/Designee will complete an audit of residents currently residing in the facility. This audit will include the resident identifier (facility identifier); reflect if a physician's order is in place for oxygen use; and if the care plan accurately reflects the use of oxygen. Don/Designee will complete weekly audits x5 medical records per week x4; then as determined by QAA. This audit will include the resident identifier (facility identifier); reflect if a physician's order is in place for oxygen use; and if the care plan accurately reflects the use of oxygen.
Failure to Implement Person-Centered Care Plan for Hearing Loss and Hearing Aids
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing hearing loss and hearing aid use for a resident, as required by its care planning process. The resident was admitted with diagnoses including paroxysmal atrial fibrillation and encephalopathy, and an MDS 3.0 assessment initially documented minimal difficulty hearing with hearing aids, later showing severely impaired cognition, moderate hearing difficulty, and continued hearing aid use. Despite these documented needs, review of the resident’s care plan, last revised on 03/13/26, showed no problem focus related to being hard of hearing or wearing hearing aids and no interventions for hearing aid care or storage. Staff interviews confirmed the absence of a hearing loss/hearing aid care plan, and the Administrator reported that the resident’s hearing aids had been lost and subsequently reordered, with new aids arriving on 03/23/26. Policy review showed that the facility’s interdisciplinary team was required to periodically review and revise care plans based on resident goals, preferences, and needs, but this was not done for the resident’s hearing loss and hearing aid management. This deficiency was cited for failure to implement a comprehensive person-centered care plan for hearing aids and hearing loss for one resident reviewed for care plans, under Complaint Number 2802107.
Failure to Care Plan for Residents’ Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans addressing pressure ulcers for two cognitively intact residents. Resident #106 was admitted with multiple medical diagnoses, including essential hypertension, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. The most recent MDS 3.0 assessment showed the resident had an unstageable pressure ulcer upon admission. A progress note dated 02/18/26 documented that this resident had a stage II pressure ulcer, yet review of the resident’s care plan revealed no care plan or interventions addressing the stage II pressure ulcer. Resident #107 was admitted with diagnoses including rheumatoid arthritis, chronic obstructive pulmonary disease, and a cognitive communication deficit, and was also assessed as cognitively intact on the most recent MDS 3.0. A skin evaluation dated 02/05/26 documented a pressure injury to the sacrum that was present upon admission. However, review of this resident’s care plan showed no plan or interventions for a pressure ulcer. During an interview on 03/20/26, the MDS coordinator and the DON confirmed that the care plans did not address the residents’ pressure ulcers or contain related interventions. Facility policy titled “Care Planning,” dated 09/2013, requires that a comprehensive care plan for each resident be developed within seven days of completion of the resident assessment, but this was not done for these residents’ pressure ulcers.
Failure to Develop Comprehensive Care Plan for Ongoing Fungal Dermatitis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan addressing an ongoing skin rash for a resident with multiple medical conditions, including cerebral infarction with left hemiplegia, mood disorder, HTN, and epilepsy. A quarterly MDS assessment documented moderate cognitive impairment and a need for staff assistance with ADLs, but indicated no skin issues. However, repeated shower sheet documentation over the course of two months noted redness under both breasts and in the groin area, with staff recording that the redness had worsened and that it had been present for months. Interventions documented on the shower sheets were limited to lotion, powder, and brief notations, without evidence of a formal, measurable care plan. Further review of the medical record showed that a Wound NP later evaluated the resident and diagnosed extensive fungal dermatitis involving the skin folds under both breasts, the periumbilical area, groin, and buttocks, with specific measurements recorded for several affected areas. Despite this documented, ongoing rash and subsequent wound evaluation, there was no evidence in the medical record that a comprehensive person-centered care plan with measurable objectives and timetables was developed to address the skin impairment. The MDS nurse confirmed the absence of such a care plan or documented interventions to treat or prevent worsening of the rash, and the facility’s care plan policy required a comprehensive person-centered care plan for each resident to meet physical, psychosocial, and functional needs.
Plan Of Correction
F656 Comprehensive Care Plans The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 10 has a new care plan that contains a comprehensive person-centered care plan to address an ongoing rash and interventions in place to treat/prevent worsening of the rash per MDS nurse on 3-12-26. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A review of all like residents with wounds supports that they all have care plans related to their wounds in place.Completed by MDS nurse on 3-24-26. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Corporate nurse in-service the MDS nurse on 3-24-26 that the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident issues. The care plan must be done immediately upon collecting the information. How the corrective action will be monitored to ensure the deficient practice will not recur.audits began on 3/25/26 by DON/designee. All residents with skin conditions will be audited weekly by the DON to ensure that there is a care plan in place to address the skin condition . DON is doing a weekly audit reviewing all skin conditions X4 weeks X 2 months. Findings submitted to weekly QAPI committee. If a concern is found during the audit correction will be done by the MDS nurse and further redirection and education done.
Failure to Timely Care Plan for Resident Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement a comprehensive, measurable care plan addressing elopement risk for a resident identified as being at risk for wandering and elopement. The resident was admitted with multiple diagnoses including anxiety, chronic kidney disease, type 2 diabetes, cognitive communication deficit, Parkinson’s disease, and dementia without behavioral disturbance, and had a legal guardian. An initial wander-risk evaluation in late 2025 identified the resident as low risk for wandering, and an annual MDS assessment documented that the resident was cognitively intact, did not wander, and required partial to moderate assistance with ambulation using a wheelchair. A subsequent wander-risk evaluation in early 2026, completed by an LPN, showed the resident had progressed to a moderate risk for wandering, but the section of the form asking what interventions would be care planned was left blank. A discharge, return-anticipated MDS again documented that the resident did not wander and required partial to moderate assistance with ambulation. A later wander-risk evaluation in mid-February 2026, completed by an MDS/RN, identified the resident as high risk for wandering, and again the section for care plan interventions was left blank. On the same date, a progress note documented that the resident pushed on an exit door, activated the door alarm, and was found on his right side outside the emergency exit door with his wheelchair beside him after an unwitnessed fall; he was assessed and brought back to the nursing station for closer monitoring. A facility investigation confirmed that the resident had exited through an emergency exit door on a hall under construction and had been outside for less than five minutes, with alarms and egress doors functioning and staff responding immediately. Interviews with the LPN and MDS/RN revealed that nurses completed wander-risk assessments and the MDS/RN handled care planning, that the LPN had never completed the care plan intervention section of the wander-risk tool, and that the MDS/RN did not initiate an elopement risk care plan when the resident’s risk level increased from low to moderate because the IDT believed the resident was not an elopement risk. The Administrator and DON confirmed that a care plan should have been initiated when the resident began self-propelling around the facility and that this was not done until after the elopement event, despite facility policy stating that assessments are ongoing and care plans are revised as resident conditions change.
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