F0657

F

Failure to Involve Residents/Representatives and Update Interdisciplinary Care Plans for Changing Clinical Needs

Council Bluffs, Iowa Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to develop, review, and revise comprehensive care plans with an interdisciplinary team that included residents and/or their representatives, and to update care plans when residents’ conditions changed. Multiple residents and family members reported that care plan conferences had not occurred since a change in facility ownership, despite prior practice of quarterly meetings. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and diabetes, had a baseline care plan and a signed POA document, but there were no care conference attendance sheets, and the family stated they had not been included in care plan meetings since the new company took over. Another cognitively intact resident and that resident’s son both reported they had never been invited to care conferences since admission, and the social services director acknowledged that many care conferences were not completed and that residents and families had not been part of quarterly assessments.

The facility also failed to revise care plans to reflect significant changes in residents’ clinical status and treatment orders. One resident with intact cognition and a right femur fracture was being transferred with a whole body mechanical lift per therapy evaluation and documentation, but the care plan still listed stand-pivot transfers with one staff and a gait belt; staff reported they had not received updated transfer information and expected therapy to update the care plan. Another resident with moderate cognitive impairment and multiple diagnoses had a care plan with 19 focus areas whose interventions had largely not been updated since the prior year, despite the facility no longer offering restorative nursing services; there was no EMR documentation of care conferences or timely updates, and late entries were added to progress notes only after surveyor inquiry. A resident who experienced a fall, hospitalization, and diagnosis of Influenza A had a marked decline in transfer ability and required a full-body mechanical lift and transmission-based precautions, but the care plan was not updated to reflect the new transfer status or the need for PPE until after surveyor review.

Additional failures involved skin integrity and catheter-related care planning. One resident admitted with a Stage 2 pressure ulcer and later placed on and then removed from an indwelling urinary catheter had care plan interventions that continued to reference catheter care and Enhanced Barrier Precautions for the catheter after the catheter was discontinued by physician order; the MDS showed the resident as incontinent without a catheter, but the care plan was not revised. Another resident at risk for pressure injuries developed in-house acquired moisture-associated skin damage on the buttocks and a deep tissue injury on the right heel, with multiple wound treatment orders and documentation of a scoop mattress and lack of repositioning aids; however, the care plan did not include MASD, the DTI, or related interventions such as pressure-reducing devices or nutrition/hydration measures. A different resident admitted without pressure injuries developed in-house Stage 2 pressure ulcers on the buttocks and a DTI on the right heel; the care plan contained no prevention focus, goals, or interventions until after the wounds occurred.

Further, residents with existing or worsening pressure injuries did not have their care plans revised to reflect new or escalated needs. One cognitively intact resident with an in-house Stage 2 sacral pressure ulcer later required surgical debridement of a Stage 4 sacral ulcer with exposed bone and a wound vacuum; the care plan showed a generic focus on potential for pressure injury and an in-house Stage 2 sacral ulcer but no new interventions after the ulcer progressed and the resident returned from the hospital with a wound vac and more advanced wound status. Another cognitively intact resident at risk for pressure ulcers developed unstageable skin on 12/23, but there was no care plan update or added interventions for this finding. Interviews with the MDS coordinator, DON, RN staff, and social services indicated that the MDS coordinator was primarily responsible for building and updating care plans, floor nurses generally did not update care plans, and care conferences were not consistently scheduled or documented with IDT participation, residents, or families, resulting in multiple care plans that were outdated, incomplete, or not reflective of current clinical orders and conditions.