Care plans were not reviewed and revised to match current assessments for two residents. One resident’s diabetes plan did not reflect new insulin coverage or therapy-documented declines in mobility and transfers, while another resident’s plan still included psychotropic-medication concerns despite no current antipsychotic orders and did not match observed non-ambulatory status, lack of prosthetics, and preference to remain in bed.
Failure to revise care plan for neck brace use: A resident with ESRD, DM, and a cervical spine fx after falls was ordered to wear a neck brace at all times, but staff observed him without the brace and he said he did not like wearing it while eating. The care plan included assistance with the collar, yet the facility could not provide documentation of refusal, and the DON stated refusals should be documented and the MD notified.
A resident with cerebral infarction, COPD, encephalopathy, malnutrition, and bilateral hand contractures was observed repeatedly lying in bed without any hand splints, orthotics, or braces present. Staff, including a CNA and LPN, knew the resident had contractures and needed full ADL assistance but were unaware of any current splint use, while the record showed no current orders and no documentation of refusal. The care plan still listed RNP interventions for PROM and splint/brace application even though the Care Plan Coordinator confirmed the resident was no longer on contracture management or using splints and that the plan should have been revised.
Failure to update care plan after change in condition: A resident was hospitalized with acute urinary retention and constipation related to neurogenic bowel, but the care plan was not revised to reflect the new diagnosis or related interventions. The MDS Director and MDS Coordinator stated they were unaware of the hospital transfer and acknowledged the care plan should have been updated to support coordinated, individualized care.
Care plans were not reviewed and revised for 3 residents. One resident's smoking status was documented inconsistently, with staff describing the resident as a safe smoker while the care plan still reflected supervision due to poor safety awareness. Two residents had incorrect code status information in their care plans, with one care plan listing DNR despite a Full Code order and another listing Full Code despite a DNR form.
A resident with significant mobility impairment and a history of repeated falls had a fall care plan that was not accurately revised after new fall events and IDT discussions. The record showed multiple falls, including being found on the floor near the bed or wheelchair and sliding from the wheelchair, while the care plan continued to list broad interventions such as frequent rounding and medication review without clear documentation of specific changes discussed by the IDT. Interviews with the LPN/MDS coordinator and DON confirmed the care plan was not updated to reflect the resident’s chair changes or medication-related discussion after falls.
A resident receiving hospice services had conflicting advance directive documentation, including a prior signed DNR, a later Full Code acknowledgment, and physician orders reflecting Full Code. The care plan still listed DNR rather than the resident’s current Full Code status, and staff interviews showed inconsistent understanding of the resident’s code status.
Delayed care plan revision for resident behaviors. A resident with cognitive impairment, schizophrenia, psychosis, anxiety, and a history of TBI repeatedly yelled, accused staff and residents of hitting him, and engaged in self-injurious behaviors such as biting himself and picking at scabs. During one incident, staff heard a loud smack and the resident alleged he had been slapped, but he was not assessed for marks or skin changes, and staff later confirmed the behavior care plan had not been initiated until much later despite the behaviors being known to multiple staff members.
Care plan not revised for oxygen administration. Two residents had physician orders for specific O2 flow rates and humidification, but observations showed one resident receiving O2 at a higher rate with an empty humidity bottle and self-adjusting his O2, while another resident was also receiving O2 at a higher rate with the concentrator out of reach and the resident's daughter adjusting or removing the O2. The care plans included oxygen as ordered but did not address these resident or family actions.
A resident with diabetes, malnutrition, heart disease, and skin cancer had forehead and scalp dressings after outpatient lesion removal, but the facility did not include wound monitoring or care in the comprehensive care plan. The active orders and MARs/TARs did not address the head wounds, and the MDS Coordinator and DON confirmed the IDT care plan had not been revised to reflect the resident’s wound needs.
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