A resident with chronic respiratory failure with hypoxia and diabetes had physician orders for continuous O2 and compression stockings, but was observed without either in place. The care plan did not document the oxygen or compression stocking interventions, and the DON stated refusals also were not documented.
A resident with sick sinus syndrome and a lumbar compression fracture was observed using O2 via NC and wearing elbow pads, with orders for continuous PRN O2 and elbow protectors at all times. The care plan did not include these current interventions, and the CRN and CNO stated the plan should have reflected them when ordered.
A resident with CKD, muscle weakness, and difficulty walking had a care plan for impaired mobility and fall risk that directed staff to keep the call light within reach. Surveyors observed the resident seated in a chair with the call light clipped to the wall on the opposite side of the bed and out of reach; the resident said it was always there. The CNO stated the resident spent most of the day in the chair and preferred the call light clipped to the wall, and this preference was not care planned.
A resident with cerebral palsy and depressive disorder had conflicting code status documentation in the medical record: the emergency care document showed full code, while the care plan listed DNR and no CPR. The DON stated the care plan was completed in error and should have been revised but had not been.
A resident with femur fracture, lymphedema, osteoporosis, and severe cognitive impairment had a care plan for BLE edema and impaired skin integrity that was not revised when TED hose were discontinued and Tubi-Grip support bandage was started. The physician record and follow-up note documented the change in compression treatment, and an LPN CN confirmed the care plan should have been updated.
A resident with quadriplegia, schizoaffective disorder, dysphagia, and hypotension had a care plan that listed halo bars for bed mobility, but staff observed no halo bar attached to the bed. The CRN stated the resident had been moved to another room, did not want the device installed, and the care plan should have been updated to reflect the change.
A resident with a history of anemia, moderate dementia, and chronic pain had active orders for aspirin for CAD and sertraline (Zoloft) for depression and chronic pain, but the comprehensive care plan was not revised to reflect current diagnoses and medication indications. The care plan continued to reference anemia and daily aspirin for antiplatelet therapy and included a directive to administer antidepressants for chronic pain without specifying sertraline’s use for both depression and chronic pain. An MDS nurse acknowledged that the resident no longer had an active anemia diagnosis and that the care plan should have been updated to clarify the current clinical rationale for aspirin therapy and the indication for sertraline.
Surveyors identified that the facility did not develop and revise comprehensive care plans in a timely and complete manner for two residents. One resident with COPD and Bipolar II disorder had a current care plan missing interventions for cognition, ADL self-care deficits, fall risk, nutrition, pressure ulcer risk, and pain, and ongoing issues from a prior care plan were not carried forward. Another resident with diabetes and dementia did not have a comprehensive care plan completed and signed within the required timeframe after admission. The DON acknowledged that these care plans were not completed in a timely manner, placing residents at risk of adverse outcomes when care plans were not updated as needs changed.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
Surveyors found that the facility did not revise care plans to include new physician orders for two residents. One resident with a right leg fracture and edema had an order for a Tubi grip for edema management, but this intervention was not added to the care plan or TAR, and the resident was repeatedly observed without the Tubi grip in place despite reporting ongoing swelling. Another resident with COPD, depression, and cardiomegaly had a new order for continuous O2 at 3 LPM via NC, but the care plan still listed only older O2 orders at different settings and was not updated to reflect the current prescription.
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