The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
Failure to Update Care Plan for Dementia Diagnosis: A resident with dementia with psychotic disturbance had a quarterly MDS showing severely impaired cognition and delirium, but the care plan did not include a dementia care plan or documentation that one was developed during the quarterly review. Staff interviews confirmed the resident required total care, was confused, and yelled out for help, and the MDS nurse and Nurse Supervisor stated a dementia care plan should have been in place.
Care plans were not revised after quarterly MDS reviews for two residents. One resident with dementia, wandering, and TBI still had 15-minute checks listed even though they were not being done, and staff said the intervention was outdated. Another resident with Alzheimer’s dementia and a Swahili language barrier had a communication care plan that did not include expected supports such as a communication board or translator services, despite staff confirming they could not communicate with the resident without Swahili-speaking staff.
A resident with atrial fibrillation and hypertension had their anticoagulant medication changed from Coumadin to Eliquis, but the care plan was not updated to reflect this change. Despite two MDS assessments occurring after the medication switch, the care plan continued to reference the discontinued medication and related monitoring, and staff confirmed that the care plan should have been revised.
A resident with cognitive impairment and psychiatric diagnoses was not invited to participate in required quarterly care plan meetings, and there was no documentation of efforts to involve the resident or their representative in the care planning process, contrary to facility policy.
A resident with complex medical needs, including metastatic cancer and multiple hospital readmissions, did not have their comprehensive care plan reviewed or revised after a scheduled quarterly MDS assessment or following readmissions, contrary to facility policy. Staff interviews confirmed a lack of awareness regarding the missed care plan updates.
The facility did not ensure that care plans were reviewed and updated by the IDT after comprehensive, significant change, and quarterly assessments for several residents, including those with epilepsy, pressure ulcers, Alzheimer's disease, and severe cognitive deficits. Documentation and interviews confirmed that required care plan meetings did not occur, and care plans were not revised to reflect residents' current conditions, with staff citing staffing challenges as the cause.
A resident with COPD and chronic pain syndrome, who was cognitively intact, was not provided the opportunity to participate in required quarterly care plan meetings. Facility records lacked evidence of care plan meetings, participation, or documentation of refusals, and staff confirmed that the meetings were not held or documented as required.
A resident with severe cognitive impairment and a history of stage 2 pressure ulcers had their wounds resolved and treatment orders discontinued, but the care plan was not updated to reflect the healing of the ulcers. Despite care plan meetings and facility policy requiring timely review and revision, the care plan continued to list the resolved wounds and interventions.
A resident with a history of stroke and dysphagia was not provided with built-up utensils during meals, despite physician orders and care plans indicating their necessity. Observations showed the resident eating without assistance, and staff interviews revealed a lack of awareness about the resident's current needs. The care plan and documentation were not updated to reflect the resident's actual level of care, leading to a deficiency.
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