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:
Incomplete care plans for oxygen therapy and dentures. Two residents had planned and provided services omitted from their comprehensive care plans. One resident with COPD had O2 therapy documented, but the care plan was delayed and did not include newly received dentures or current oral/dental status. Another resident with pneumonia and CHF had an active O2 order and was receiving oxygen, but oxygen was not included in the care plan.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use: The facility failed to ensure care plans reflected key resident needs and behaviors for three residents. One resident’s plan did not include hospice services despite active hospice care and hospice aide visits. Another resident’s plan did not include use of a sensor pad even though he relied on it to call for help. A third resident’s plan did not reflect that he removed and reapplied his O2 cannula, although he stated he managed his O2 himself and an RN confirmed it.
A resident with multiple fall risk factors and several recent falls had a care plan that listed floor mats, but staff did not have the mats in place until later and could not locate corresponding orders in the EMR. The resident also received multiple high-risk meds, including a benzo, antidepressant, gabapentin, and opioid, yet the care plan did not address medication-related fall risk despite the resident’s falls and the meds’ known side effects.
A resident with PTSD had the diagnosis listed in the face sheet, physician visit, and quarterly MDS, but the care plan did not include PTSD or related interventions. The DON stated she did not see PTSD in the care plan and noted it was important to include the diagnosis so staff could document interventions such as avoiding triggers. Facility policy required person-centered trauma-informed care and individualized interventions, preferences, and triggers to be documented in the care plan.
The facility failed to include EBP instructions in the care plans of residents with a G-tube, a chronic wound, and an indwelling catheter. Observations showed PPE carts and signs directing staff to use gowns and gloves for direct care, but one care plan did not address EBP for G-tube or personal care, another lacked EBP guidance for wound care, and a third lacked EBP guidance for catheter care. The DON stated EBP should be care planned when required and staff were expected to follow the care plan and PPE guidance.
Care plans were inaccurate for multiple residents because current needs were omitted and resolved or discontinued issues remained listed. A resident with a pressure injury had no pressure injury care plan, another resident’s healed venous wound remained on the plan, one resident’s AC therapy and thrush were not updated, a resident on AC medication had no related focus area, and a resident with impaired vision had no vision-related care plan entries.
Incomplete care plans for oxygen therapy and dentures
Penalty
Summary
The facility failed to ensure that all planned and provided services were included in the comprehensive care plans for 2 of 19 sampled residents, Resident 34 and Resident 9. For Resident 34, the electronic health record showed a readmission with diagnoses including COPD, diabetes, and anxiety disorder, and the resident was able to make needs known. The quarterly MDS showed the resident received O2 therapy and had broken or loosely fitting full or partial dentures. During interview, Resident 34 stated they had dentures, but the bottom dentures did not fit right and had been taken a few weeks earlier to be fixed and had not been returned. Records also showed new dentures were received on 04/06/2026, but the focused care plans for ADL self-care performance deficit and oral/dental health problems did not include dentures. The focused care plan for COPD showed the resident was on O2 therapy, but it was not initiated until 06/15/2026, despite the resident having an order for continuous O2 at 2 L/minute via NC starting 05/27/2026. For Resident 9, the electronic health record showed admission with diagnoses of pneumonia, diabetes, and CHF, and the resident was able to make needs known. The record showed a provider order for O2 at 2 liters per minute with a start date of 11/19/2025, and the MDS showed the resident was receiving oxygen during the stay. However, the current plan of care reviewed on 06/17/2026 did not include oxygen. Staff stated the resident should have had a care plan in place for oxygen, and the DNS stated it was the expectation that residents with CHF who received oxygen had it included in their comprehensive care plan, but this did not happen for Resident 9.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that reflected identified resident needs for three residents. The report states that the care plan for Resident #7 did not reflect hospice services, the care plan for Resident #44 did not reflect use of a sensor pad, and the care plan for Resident #81 did not reflect that he took off and put on his oxygen cannula. The facility policy required a comprehensive care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #7 was a female with diagnoses including cerebral infarction and malignant neoplasm of the colon. Her MDS reflected severe cognitive impairment, moderate assistance with ADLs, and hospice care. Her care plan dated 02/17/2026 did not include hospice services, even though active orders reflected admission to hospice for CVA starting 02/04/2026. During observation, she was in bed with a hospice aide applying lotion to her legs, and she stated hospice came and gave her baths and showers. Resident #44 was a male with Parkinsonism, muscle spasms, and seizures. His MDS reflected moderate cognitive impairment, substantial assistance to total dependence for most ADLs, use of a manual wheelchair, and maximal assistance for locomotion and mobility. His care plan dated 05/01/2026 included an ADL self-care deficit and an intervention to encourage use of the call bell, but it did not reflect his sensor pad. During observation, his sensor pad was lying on his bed while he was seated in a tall wheelchair in his room, and he stated he would use the sensor pad to call for help if needed. Resident #81 had acute and chronic respiratory failure with hypoxia and was noted to have moderate cognitive impairment and need for minimal to moderate assistance with ADLs. His care plan addressed oxygen therapy and nebulizer use, but it did not reflect that he removed and reapplied his oxygen cannula. During observation, oxygen equipment was present near his bed, and he stated he used oxygen at night, put it on and took it off himself, and turned the concentrator on and off; an RN confirmed he could remove and replace his nasal cannula.
Incomplete Fall Prevention Care Planning
Penalty
Summary
The facility failed to develop, implement, and revise the comprehensive person-centered care plan for one resident with a history of falls. The resident was admitted with diagnoses including osteoarthritis, spinal stenosis, neurosarcoidosis, obstructive sleep apnea, macular degeneration, and restless leg syndrome. The resident’s care plan, initiated after a fall risk assessment, identified the resident as at risk for falls and fall-related injury due to generalized weakness, limited endurance, impaired balance, unsteady gait, history of falls, and decreased vision, and it included floor mats to the sides of the bed per orders. Record review showed the resident experienced three falls over a little more than one month, including one fall that resulted in shoulder pain and prompted diagnostic imaging. During interview, the resident stated that fall mats were not currently in place but would be liked. The ADON stated fall mats were identified in the care plan but could not locate fall mat orders in the EMR. A CNA stated staff were told by the DON or unit nurse when to place the mats and that staff first started using fall mats on the night of 6/10/26. The Administrator stated the facility was aware of the resident’s increased falls, had discussed the falls with the resident, and had recently ordered additional mats because the facility did not have enough. The resident’s record also showed use of multiple high-risk medications with fall-related side effects, including diazepam, escitalopram, gabapentin, and oxycodone. Review of the care plan showed no interventions addressing medication-related fall risk despite the resident’s falls and the presence of these medications. Facility policies stated that staff, with physician input, would implement a resident-centered fall prevention plan based on specific risk factors and modify care plans when goals and objectives were not achieved.
Missing PTSD Diagnosis and Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #4 that included his PTSD diagnosis and related interventions. Record review showed the resident was admitted and later re-admitted with PTSD, and his physician visit and quarterly MDS also listed PTSD as an active diagnosis. However, the care plan dated 4/22/206 did not include PTSD. During interview on 6/10/2026 at 4:48 PM, the DON stated she did not see PTSD in Resident #4’s care plans and said it was important to include the diagnosis so staff could show interventions such as avoiding certain triggers. The facility’s PTSD Management in Long-Term Care policy stated that residents with PTSD should receive person-centered trauma-informed care and that individualized interventions and resident preferences and triggers should be documented. The facility’s Care Plan policy stated care plans should include identified problems and needs, measurable goals and expected outcomes, and interventions and services to be provided.
Failure to Include EBP in Resident Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included enhanced barrier precautions (EBP) for 3 of 5 residents reviewed who were identified to be on EBP. One resident had intact cognition, required moderate assistance with bathing, had a G-tube, and diagnoses included Parkinson’s disease, narcolepsy, anxiety, and dysphagia. That resident’s care plan addressed incontinence and G-tube care, but did not include instructions for EBP when staff provided G-tube care or personal care. The resident’s active medication orders directed that numerous medications be crushed and administered through the feeding tube, and a sign outside the room directed staff to wear a gown and gloves for direct care, including G-tube care. The DON stated G-tube care was one instance when EBP should be used and that EBP should be care planned when required. A second resident had severe cognitive impairment, obesity, an unstageable pressure ulcer, and moisture associated skin damage. The resident’s wound assessment identified a stable coccyx ulcer, but the care plan lacked any guidance for EBP use. During observation, an isolation cart outside the room had a contact precaution sign for the roommate and did not address whether the resident was on EBP; the cart contained gloves, masks, and eye/face protection, but no gowns. A nursing assistant stated gowns and gloves were not needed for care of that resident and entered the room without wearing either. A third resident had moderate cognition, an indwelling catheter, renal insufficiency, and urinary retention. The care plan included catheter change, daily catheter care, and infection monitoring, but did not include EBP instructions related to the catheter. Observation showed a cart outside the room with gowns and gloves and a sign identifying the resident as on EBP with instructions to wear gowns and gloves for direct care, including catheter care. The DON stated staff were expected to follow resident care plans and the facility policy regarding PPE for EBP.
Care plans missing current needs and unresolved conditions
Penalty
Summary
Care plans were not accurate for 5 of 22 sampled residents because needed care was not included and some resolved or discontinued conditions were not removed. The deficiency involved Residents 7, 5, 27, 4, and 98, and was identified through interview and record review. The report cited WAC 388-97-1020(1)(2)(a)(b). Resident 7 was admitted with stroke and right-sided weakness and had a pressure injury to the bottom. The resident stated their bottom was very sore and was observed lying flat on their back with heels on the mattress. The EHR showed no actual pressure injury care plan, even though a weekly skin assessment documented a stage two pressure ulcer to the bottom. Staff stated the resident should have had a pressure injury care plan but did not. Resident 5 had a focused skin integrity care plan that identified a chronic venous leg ulcer/wound on the right lower leg, but later EHR review showed no documentation of a current venous wound and the MDS showed zero venous ulcers/wounds. Resident 27 had a care plan that still listed anticoagulant therapy and thrush, but the EHR showed no current anticoagulant therapy or thrush infection, and staff stated both conditions should have been updated or resolved in the care plan. Resident 4 received an anticoagulant medication, but the plan of care had no focus area for anticoagulant use. Resident 98 had impaired vision noted on the MDS and stated they could not see well and needed to see the eye doctor, but the care plan had no problem, goal, or intervention related to visual deficit or glasses use.
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