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.
Care plans were not developed and implemented to reflect the current needs of two residents. One resident with Alzheimer's disease, suicidal ideations, delusional disorder, mood disorder, and bipolar disorder had an active order for quetiapine, but no care plan for antipsychotic use. Another resident with chronic pain and depression had active orders for sertraline, methadone, and PRN oxycodone, but the care plan lacked goals, interventions, and side effect monitoring for pain management and antidepressant use.
A resident with a history of stroke and left-sided weakness, including a flaccid left arm, had a care plan for functional mobility that required two staff for all transfers. Despite this, a CNA attempted to transfer the resident alone from a wheelchair to a bed, the transfer failed, and the CNA lowered the resident to the floor. The resident was assessed with no visible injuries, and both the CNA and the Administrator later confirmed that the care plan requiring two-person assistance for transfers was not followed.
Surveyors found that the facility failed to develop, update, and implement accurate care plans for multiple residents. Two residents were repeatedly transferred by CNAs using manual stand-pivot techniques under the arms, despite existing ADL care plans and CNA assignment sheets requiring use of a mechanical lift, sit-to-stand device, or specified assistive equipment and staffing levels. In addition, a resident receiving hospice/palliative care had no corresponding hospice or palliative care plan or interventions in place, and another resident who was always incontinent of bowel and bladder per the MDS had no care plan addressing incontinence. The DON confirmed that these care plans did not reflect the residents’ current needs.
Care plans were not developed or implemented to reflect the current needs of two residents. One resident had a pacemaker documented in the chart, with nursing notes showing attempted device checks and communication with the clinic, but no care plan goals or interventions for pacemaker monitoring. Another resident had recurrent GI issues, including intestinal obstruction, abdominal pain, distention, loose stools, ER transfer, and a recent SBO, yet the care plan lacked goals and interventions for the GI concerns.
Care plans did not reflect current resident needs for two residents. One resident with a cardiac pacemaker had no care plan goals or interventions for the pacemaker despite orders and MDS documentation, and another resident with COPD, CHF, and chronic edema had a care plan that did not include daily Tubigrips use or match the resident’s actual routine of sleeping in a recliner and receiving staff help with compression garments.
A resident with dementia, visual loss, and a history of falls was not provided with hip protectors as required by their care plan and physician orders. Staff interviews revealed a lack of awareness and follow-through regarding this intervention, and it was confirmed during the survey that the resident was not wearing hip protectors, despite being at high risk for falls.
A resident with a choking risk, underweight status, and a care plan for nutritional concerns was observed eating breakfast and lunch in bed without supervision. The record showed provider orders for OOB for all meals and meal monitoring, but surveyors found the resident eating independently and unmonitored instead of being OOB as ordered and reflected in the care plan.
A resident with dementia and anxiety suffered a leg fracture, but the care plan was not updated with new goals or interventions following the injury. Review of records showed the care plan had not been revised to address the resident's new needs after the incident.
Failure to Monitor Psychotropic Medication Side Effects: The facility did not develop or implement complete care plans with measurable goals and interventions for psychotropic medication use for three residents. One resident with depression was receiving antidepressant and anti-anxiety meds, another resident with Parkinsons, depression, and delusional disorder was receiving antidepressant, anti-anxiety, and antipsychotic meds, and a third resident with anxiety disorder, dementia with psychotic disturbance, delusional disorders, and major depressive disorder was receiving antipsychotic and anti-anxiety meds. Although the care plans called for Q-shift monitoring of side effects and effectiveness, the clinical records lacked evidence that monitoring was being done, and the DON stated the facility had never monitored anyone for side effects of the medications identified.
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