A resident with atrial fibrillation was ordered Eliquis and the MDS showed anticoagulant use, but the care plan did not address anticoagulant therapy. Staff interviews confirmed the plan should have included monitoring and care guidance related to bleeding risk, bruising, and related interventions.
The facility failed to develop comprehensive care plans for two residents. One resident was receiving continuous oxygen and nebulizer treatments for respiratory failure, but oxygen therapy was not addressed on the care plan and staff confirmed there was no oxygen order in place. Another resident had severe cognitive impairment and spoke Vietnamese, but the care plan did not identify communication needs despite staff noting language and communication concerns.
Failure to develop comprehensive care plans for oxygen therapy and wounds. Two residents with physician orders for O2 therapy had no care plan focus areas for oxygen use, and a resident with multiple pressure ulcers had no wound care plan. The DON confirmed the missing care plans, and the RN MDS Coordinator acknowledged the wound care plan for the resident was not developed.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
Incomplete Oxygen Therapy Care Plan: A resident with asthma had a physician order for oxygen at 2 LPM via NC, but the comprehensive care plan did not include individualized interventions tied to the prescribed flow rate. The MDS Coordinator confirmed the plan lacked specific oxygen-related guidance for staff, including following the ordered rate.
Care plan not updated for a resident with dementia and severe cognitive impairment who was identified as wandering and exit-seeking. Staff observed the resident wandering the halls, touching the med cart, and entering other residents’ rooms, while interviews confirmed this happened often. The care plan addressed location checks but did not include interventions for entering other residents’ rooms.
Incomplete Care Plan and Tube Feeding Not Followed as Ordered: A resident with dysphagia, gastrostomy status, and a feeding tube had a care plan that addressed aspiration risk and nutritional stability, but staff did not follow the physician’s tube feeding order. Observations showed Jevity 1.5 infusing during the day even though it was ordered only overnight, and an LPN confirmed the pump should have been off by 6:00 AM. The CMI Director stated the care plan should always be followed.
A resident with multiple serious medical conditions experienced a significant downward weight trend over several months, documented by dietary staff who noted varied meal intake and recommended liberalizing the diet, adding double eggs at breakfast, and monitoring weight. Although the MDS was coded to indicate weight loss on a physician-prescribed weight-loss regimen, there was no evidence of an intentional weight-reduction plan in the record. The resident’s care plan contained no goals, interventions, or revisions related to the documented weight loss, despite facility policy requiring nurses, the CMD, and the IDT to update care plans to reflect current needs, and leadership confirmed that no care plan updates were made for the weight decline.
A resident who was cognitively intact and identified on the MDS as being at risk for pressure ulcers had a triggered CAA for pressure ulcers, but the EMR care plan did not address that risk. The MDS Coordinator confirmed no care plan was developed for the pressure ulcer concern, and the DON stated her expectation was that triggered CAAs would be reflected in the care plan.
Surveyors found that the facility did not follow its RAI/care planning policy or honor the documented wishes of two residents who wanted to remain in LTC. One resident with multiple conditions, including hypertension, depression, and traumatic brain injury, had a care plan specifying long‑term residency with interventions such as activity participation and Social Services involvement. Another resident with ESRD on dialysis, paraplegia, hypertensive heart and CKD, diabetes, hypertension, and seizures had a care plan stating no desire for discharge, a need for 24‑hour care, and a family unable to provide care, with instructions to involve Social Services if interest in outside resources arose. An LPN MDS Coordinator reported that the Social Services Director is responsible for initiating transfers/discharges but could not explain why the required process was not followed for these residents.
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