F0656

E

Failure to Develop Comprehensive, Measurable Person-Centered Care Plans for Multiple Residents

Milwaukee, Wisconsin Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents, despite clear policy requiring such plans within specific timeframes after MDS assessments. The facility’s written policy states that an interdisciplinary team, in conjunction with the resident and/or representative, must develop a comprehensive care plan within seven days of the required MDS and no more than 21 days after admission, including measurable objectives, timeframes, and services to meet physical, psychosocial, and functional needs. Interviews with the DON and ADON revealed that admitting nurses create temporary care plans, MDS staff are responsible for baseline care plans, and floor nurses are expected to update care plans, but there were gaps in execution, including the absence of an on-site MDS coordinator and reliance on remote and regional staff.

One resident with a history of intracranial hemorrhage, atrial fibrillation, hypertension, and multiple antihypertensive and anticoagulant medications did not have a comprehensive care plan addressing anticoagulant or blood pressure management. Although this resident had care plans for hypertension, arrhythmia, risk for bleeding, risk for decreased cardiac output, altered neurological status, impaired physical mobility, dehydration, and a no-added-salt diet, the care plans did not include monitoring for effectiveness and side effects of blood pressure medications and anticoagulant therapy. The goals for altered neurological status and impaired physical mobility were not aligned with those problem areas, focusing instead on skin integrity and pressure-relieving devices. The resident reported that staff had not reviewed the care plan or interventions with them.

Another resident, admitted with anoxic brain injury, chronic respiratory failure, tracheostomy, ventilator dependence, gastrostomy tube, and hypotension, was assessed on admission as at risk for pressure injuries and dependent for mobility, but a skin integrity/pressure injury care plan was not initiated until approximately 10 weeks after admission. When the skin integrity care plan was eventually started, it did not specify how often the resident should be turned and repositioned, and there was no ADL care plan documenting transfer or bed mobility status. This resident also had an indwelling catheter documented on MDS, but a urinary catheter care plan was not initiated until about six months later. The bowel incontinence care plan for this resident, and the corresponding CNA Kardex, did not include how often the resident should be checked and changed for bowel incontinence, even though CNAs reported relying on the Kardex for direction on resident care.

Several other residents who were always incontinent of bowel and/or bladder and dependent on staff for rolling left and right lacked care plan interventions specifying the frequency of incontinence checks and changes and repositioning. One resident with anoxic brain damage, dysphagia, chronic respiratory failure, quadriplegia, and a history of an indwelling catheter had bladder and bowel incontinence care plans that addressed peri care, clothing, staff assistance, and skin monitoring but did not state how often the resident should be checked and changed. Another resident with chronic respiratory failure, dysphagia, anxiety disorder, encephalopathy, gastrostomy tube, tracheostomy, and ventilator dependence had a bladder incontinence care plan without a defined frequency for incontinence care, no bowel incontinence care plan at all, and an ADL care plan that did not specify how often to reposition in bed or in the Broda chair.

Additional residents with chronic respiratory failure, neuromuscular or neurologic conditions, feeding tubes, tracheostomies, ventilator dependence, and indwelling catheters were similarly affected. One resident with myotonic muscular dystrophy and chronic respiratory failure had bowel and bladder incontinence care plans that omitted how often to check and change for incontinence, and an ADL self-care deficit care plan that only stated to ensure proper positioning for comfort without specifying repositioning frequency. Another resident with ALS, chronic respiratory failure, dysphagia, and anoxic brain damage had an ADL care plan indicating total assistance by two staff to turn and reposition “as necessary,” but did not define how often repositioning should occur. A further resident with hemiplegia following stroke, chronic respiratory failure, hypertension, and atrial fibrillation had a bowel incontinence care plan that did not specify how often to check and change, and an ADL care plan that stated assistance by one staff to turn and reposition “as necessary” without a defined schedule. Across these cases, the surveyors found that the facility did not consistently translate assessed needs—such as incontinence, bed mobility dependence, catheter use, and complex medical conditions—into comprehensive, measurable, and time-specific care plan interventions.