Care Plan Missing Nebulizer Treatment: A resident with COPD, asthma, dementia, and other diagnoses was receiving nebulizer treatments ordered for asthma, but the care plan did not identify the treatments and no self-administration assessment was completed. Surveyors observed the resident using the nebulizer without staff present, and the MDS Coordinator, DON, and Administrator all stated the nebulizer treatment should have been included on the care plan.
A resident with nicotine dependence and intact cognition was found searching for a vape while a MAC assisted and even charged and returned a vape device. The care plan identified nicotine dependence but did not address repeated possession of vapes, family bringing vapes into the room, or staff guidance for non-compliant behavior related to the facility’s no-smoking policy. Interviews confirmed staff knew vapes were not allowed, yet the issue was not included in the resident’s care plan.
A nonverbal resident with a history of brain stem hemorrhage and intact cognition was admitted with documented unclear speech, rare ability to make themself understood, and reliance on nodding, head shaking, and sign language for communication, yet no communication deficit with individualized interventions was initiated on the comprehensive care plan. Multiple assessments and progress notes by nursing, social services, APRN, and SLP consistently described the resident as nonverbal and using alternative communication methods, but these findings were not incorporated into a person-centered care plan. CNAs, an RNA, and an LPN reported using yes/no questions, body language, facial cues, and the resident’s hand signals to communicate, while also stating they did not know sign language and had not seen communication boards or structured tools, and leadership acknowledged that a communication deficit should have been care planned and that there were no facility policies guiding communication care planning for nonverbal residents.
A resident admitted with type 2 DM, CHF, CKD, and other diagnoses had a care plan that addressed DNR status, depression/insomnia meds, ADLs, pain meds, diuretic therapy, and nutrition, but did not include diabetes or interventions for monitoring complications. The resident had active insulin orders and received basal and sliding-scale insulin, while the RN and DON stated care plans should list diagnoses and interventions and be updated with MDS findings.
A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls had a care plan requiring two-person assistance with a gait belt for transfers. Despite this, a CNA attempted to transfer the resident alone from a shower chair to a w/c, during which the resident’s knees gave out and the CNA lowered the resident to the floor, causing minor knee scratches documented by an LPN. The administrator later verified that both the care plan and the posted closet care plan specified two-person transfers, while the CNA reported believing the resident was a one-person transfer and admitted not reviewing the closet care plan recently. Other CNAs and a MA-C stated they routinely checked closet care plans, which were updated as needed, to determine residents’ transfer needs.
A facility failed to keep two residents’ care plans current after falls and new interventions were identified. One resident with severe cognitive impairment and a history of falls had post-fall changes such as mattress baffles and assist bars in use, but the care plan did not clearly reflect those interventions. Another resident, who was dependent for transfers and walking and was high risk for falls, had non-skid socks implemented after an unwitnessed fall, but the care plan and Kardex did not include that intervention. The DON, MDS Coordinator, and Administrator all confirmed the care plans were not fully updated to match the residents’ current fall-related interventions.
Care Plan Did Not Address Smoking Safety: A resident with hemiplegia and a TIA/stroke history, who was cognitively intact, used a wheelchair, and was identified as a current tobacco user, had a smoking safety screen showing supervised smoking and 5-10 cigarettes per day. However, the Care Plan did not include smoking, smoking safety, or that the resident smoked. The resident was later observed smoking with supervision, and staff interviews confirmed the Care Plan should have reflected the resident’s smoking needs and that it was inaccurate.
Care Plan Did Not Address High-Risk Medications: A resident admitted with heart failure, stroke with hemiplegia, and a mood disorder received an antidepressant, anticoagulant, and diuretic, but the Care Plan did not include the use, monitoring, or precautions for these medications. The MDS and MAR confirmed the medications were being given, and the MDS Coordinator, DON, and Administrator all confirmed the Care Plan was incomplete and did not address these high-risk drugs.
The facility failed to develop and implement comprehensive care plans addressing sexual health and a consensual sexual relationship for two cognitively impaired, independently mobile residents with psychiatric and neurological diagnoses. Both residents were known to seek each other’s attention and had a prior relationship, yet their care plans only directed staff to separate and redirect them, without any individualized interventions for sexual health, privacy, or safe sex. A CNA later found the two residents on the floor with their pants down, appearing to engage in consensual sexual activity, and they were separated by staff. Subsequent staff interviews confirmed there was no documented assessment, no care plan revisions for sexual health or the relationship, no safe sex education, no established access to contraception, and no facility policy on resident sexual relations.
Incomplete Comprehensive Care Plan: A resident with multiple diagnoses, including DM, impaired mobility, a foley catheter, wounds, and dependence for many ADLs, had a care plan that did not include needed interventions for self-care deficits, wheelchair use and fall prevention, medication monitoring, black-box warnings, or wound care. CNAs relied on a closet care plan that lacked guidance for medications and wound care, and the MDS Nurse, DON, and Administrator confirmed the care plan was not comprehensive and did not contain the information needed to direct resident care.
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