A resident with L hemiplegia from stroke, nicotine dependence, and COPD had a care plan that addressed smoking but did not include interventions for smoking safety related to the resident’s abilities and deficits. The resident was cognitively intact, required substantial to maximum assistance with transfers, was dependent for ADLs, used a wheelchair, and confirmed that someone brought cigarettes into the facility. Leadership was informed that the care plan did not address smoking safety.
A resident with a foley catheter was observed with the catheter hooked to the bedframe and visible from the door. The resident stated the foley had been in place for quite some time, but the care plan lacked goals and interventions for catheter use. During review with the DON, the concern was confirmed.
A resident with a Foley catheter, neurogenic bladder, and a history of MDRO UTIs had recurrent ESBL and other resistant urinary organisms, including a hospitalization for urosepsis with polymicrobial UTI. The care plan addressed catheter care and UTI monitoring, but it did not include the resident’s recurrent MDRO history or the need for staff to use EBP during direct care, which the DON acknowledged was missing.
Failure to develop and implement care plans for suicidal ideations and oxygen use. One resident had repeated statements about wanting to be dead, suicidal ideations, and behavioral changes, but no specific care plan problem was developed to address the issue. Another resident with COPD had an oxygen order for 3 to 5 LPM, yet staff observed the concentrator set above the ordered range, did not check the setting when changing the cannula, and the TAR lacked documentation for the oxygen setting.
A facility failed to develop and implement complete care plans for several residents with current therapy, behavior, and fall-monitoring needs. One resident with quadriplegia and adaptive drinking equipment had OT orders but no therapy goals or interventions in the care plan; another resident requiring 2 staff for all care had that need documented but not fully reflected in the care plan. A resident with repeated verbal and physical aggression toward others also lacked behavior interventions, two residents receiving PT/OT had no therapy-related care plan goals, and a resident on hourly rounding after a fall had multiple missed rounds documented.
Care plans were not adequately developed or followed for bowel/bladder care and smoking. A resident with dementia and hospice services had a care plan calling for toileting checks and incontinence care every 2 hours, but documentation showed brief assistance was recorded inconsistently and was missing at the time of review. Another resident’s smoking care plan lacked appropriate goals and interventions for smoking safety, despite the facility policy requiring smoking-related privileges, restrictions, and concerns to be included in the care plan.
Care plans were missing key resident-specific needs for hospice comfort care, pain management, wandering/elopement risk, and dialysis care. A resident on hospice lacked comfort-focused interventions, a resident receiving oxycodone had no pain plan, a resident with documented wandering and exit-seeking had no wander/elopement care plan, and a resident on dialysis had no plan details for the dialysis schedule, access sites, or emergency procedures.
Care plan missing suicidal ideation goals and interventions: A resident with MS and major depressive disorder made repeated self-harm statements in the dining room, including saying [he/she] wanted to kill [himself/herself] and asking for "a gun." The care plan addressed general behavior issues and emotional distress, but it did not include goals or interventions specific to suicidal ideation, which the DON confirmed during interview.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident with an active diagnosis of Chronic PTSD had an initial assessment noting a history of physical and emotional trauma triggered by certain sounds, but the clinical record lacked evidence of interventions to prevent re-traumatization. The DON confirmed the care plan did not address PTSD, including goals or interventions related to re-traumatization prevention.
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