F0684

E

Failure to Assess, Monitor, and Care Plan for Complex Medical Conditions and Devices

Baldwin, Michigan Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to appropriately assess, monitor, document, and care plan for a cognitively intact resident with multiple complex medical conditions, including diabetes, CHF, CKD, benign prostatic hyperplasia, a history of hernia with repair, and a suprapubic catheter. The resident was observed with disheveled hair and scabbing on his head, reporting that he scratched due to itching. A skin assessment documented red, dry bilateral lower extremities with scratch marks, boggy blanchable heels, and red, excoriated posterior thighs, yet the care plan only referenced a history of skin impairment and MASD to the right posterior thigh and did not include a specific pressure ulcer risk focus, wound interventions for the heel, suprapubic exit site excoriation, or MASD prevention. There was also no care plan for pruritis despite orders for topical treatments for itchy skin.

Regarding the resident’s hernia and related pain, hospital emergency room notes documented a right inguinal hernia that was reduced with instructions for “strict return precautions,” but these precautions were not clarified or documented in the EMR. A nursing note relayed a hospital recommendation for an over-the-counter hernia support device and instructions to reduce the hernia if it returned, but there was no documentation that the resident ever received the hernia support or that ongoing hernia assessments and monitoring occurred. Subsequent nursing notes described episodes where the resident reported his hernia was “out,” received Norco, and was positioned with head down and feet up, but there was no ongoing assessment or monitoring documented. Later, the resident was sent to the ED with abdominal distention and brown emesis and was diagnosed with small bowel obstruction, right inguinal hernia, pneumatosis intestinalis, and AKI, with hospital records noting an incarcerated inguinal hernia and conservative management with a scrotal support belt; however, the care plan remained vague, not focused on the hernia, and contained no specific hernia-related interventions or updates after hospital return.

The facility also failed to adequately monitor and care plan for the resident’s CKD, hyperkalemia, hyponatremia, and CHF. Labs showed elevated potassium and reduced eGFR consistent with CKD stage III, and the practitioner added Lokelma for hyperkalemia, but there were no subsequent potassium labs in the EMR to reflect ongoing monitoring or stability on this medication, despite continued Lokelma orders and the resident at one point declining the medication. Sodium chloride and Lokelma were ordered without documentation of ongoing sodium and potassium monitoring or evidence that the resident was stable on these medications. The resident had CHF with orders for Lasix, a fluid restriction, and midodrine (first scheduled, then PRN for MAP < 65), but there was no documented CHF monitoring protocol, no baseline reference weight clearly established, and no CHF-focused care plan or interventions, despite multiple weight fluctuations and the DON’s acknowledgment that staff likely did not know how to calculate MAP and that the order lacked typical nursing home parameters.

In addition, the facility did not maintain accurate documentation or appropriate care planning for the resident’s suprapubic catheter. Staff interviews revealed confusion between a Foley catheter and a suprapubic catheter, with the EMR and MAR listing Foley catheter care orders while the resident actually had a suprapubic catheter. The resident was observed with a suprapubic catheter in place, no T-sponge, and surrounding skin that was red and excoriated, while the MAR contained both Foley catheter care orders and suprapubic catheter care orders, with the suprapubic site care order discontinued. The ADL care plan referenced Foley catheter care and a closed drainage system, but the elimination care plan described a suprapubic catheter in place for obstructive reflux uropathy and increased UTI risk, without specific suprapubic catheter interventions. Overall, the care plans contained incorrect or missing information about the resident’s current medical status and lacked pertinent interventions for the hernia, CKD, hyperkalemia, hyponatremia, CHF, suprapubic catheter, and skin conditions, and the facility did not ensure consistent assessment, monitoring, and documentation aligned with the resident’s needs and medical orders.