Failure to Follow Transfer Care Plan: Staff failed to follow a resident’s care plan requiring a mechanical lift for transfers. The resident had dementia, stroke, reduced mobility, and severe cognitive impairment. CNA8 and CNA9 transferred the resident back to bed without the lift, while an LPN reported the resident was resisting and hitting staff. The DON and Administrator stated staff were expected to follow the care plan.
A resident with a stroke history and moderate cognitive impairment had a care plan requiring two staff for transfers, but a CNA transferred the resident alone from a wheelchair to bed. The resident’s legs gave out, she was assisted to the floor and then onto the bed, and the incident was not reported right away because the CNA did not think it was a fall. The resident later developed bruising, pain, and swelling, and x-rays showed an acute distal tibia fracture.
Failure to Implement Podiatry Care in Resident Care Plan: A resident with DM, an above-the-knee amputation, and ESRD had a care plan that included regular podiatry care, but the service was not implemented as planned. The resident missed podiatry visits because they were scheduled on dialysis days, staff did not successfully arrange the appointment, and the resident’s toenail remained thick, overgrown, and touching the adjacent toe. Interviews showed the resident, dialysis staff, the podiatry MD, and facility staff all identified the missed podiatry care and the ongoing scheduling problem.
A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
The facility failed to maintain comprehensive, person-centered care plans for residents with repeated falls. Three residents with dementia and other conditions had multiple fall incidents, but their CCPs mainly documented physician evaluation and did not consistently include resident-specific interventions tied to the causes of the falls, and some interventions were not reflected on the CNA Kardex used by staff for daily care.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans and to carry out existing interventions for three residents. One resident with paraplegia and a urostomy managed her own drainage by attaching catheter tubing to her pouch and hanging the tubing over a trash can without performing hand hygiene, and her care plan lacked interventions addressing her self-care and hand hygiene despite her cognitive intactness. Another resident with hemiplegia had a physician order and care plan for a left-hand splint to be worn a set number of hours daily, yet repeated observations showed the splint unused by the TV and no documentation of implementation in the record. A third resident with hemiplegia had orders and a care plan for a right resting hand splint and a left palm guard, but observations over several days showed the right splint not in place and sitting on the bedside table, while staff interviews revealed inconsistent awareness and follow-through on splint orders and care plan directives.
Care plans for two residents with chronic pain did not include non-pharmacological interventions. One resident had chronic back pain with low back pain, osteoarthritis, and moderate cognitive impairment, and the other had chronic bilateral lower extremity and left knee pain with osteoarthritis and chronic pain. Both care plans focused on pain meds and monitoring, but omitted measures such as repositioning, heat or cold, supportive devices, and other comfort interventions that the residents said would help.
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, and staff did not consistently follow existing care plan interventions. Several residents with PEG tubes, a dialysis catheter, and a colostomy either lacked appropriate EBP care plan focuses at admission or did not have EBP practices implemented as written, including missing door signage and failure to follow tube-feeding protocols. In addition, two residents with PTSD and other mental health diagnoses had active PTSD documented in assessments and psychiatric notes, but their care plans did not address PTSD-related triggers, symptoms, or trauma-informed interventions, despite staff acknowledging these omissions and the importance of accurate, complete care planning.
A resident admitted with PTSD and other diagnoses had a trauma-informed care assessment showing distressing trauma symptoms, but the comprehensive care plan did not address PTSD or include trauma-informed interventions. Staff interviews confirmed the diagnosis was known, yet the care plan lacked the information needed for nursing, CNA, MDS, SSD, DON, and ED staff to identify needs, triggers, and resident-centered interventions.
Failure to develop a care plan for a resident’s tracheostomy care. The resident had a tracheostomy, COPD, chronic respiratory failure with hypoxia, and received oxygen therapy, suctioning, and tracheostomy care. The care plan addressed communication difficulty related to the tracheostomy, but it did not include a tracheostomy or respiratory services focus area. Staff and the DON confirmed there was no tracheostomy-specific care plan, despite an order for tracheostomy care every shift.
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