Failure to Offer Quarterly Care Conferences: A resident with depression, anxiety, chronic pain, and DM was not consistently offered or documented for quarterly care conferences. The EMR showed one conference note where the resident declined participation, but no evidence of any later conferences being offered, provided, or refused. The resident said she did not always know the plan of care, and the family member said she had not been invited in over a year and did not know what was going on with the resident’s care.
Care plans were not revised to match current assessments, therapy notes, and resident preferences for several residents. One resident’s care plan still showed independence despite MDS findings of severe cognitive impairment, incontinence, and need for assistance with ADLs. Another resident’s plan did not match therapy’s transfer guidance or current feeding tube use, a third resident’s preference for female caregivers was not documented, and a fourth resident’s plan did not reflect therapy’s recommendation to have meals out of bed.
A resident with moderate cognitive impairment and late-onset Alzheimer’s disease had a care plan that did not accurately reflect current function with toileting, transfers, and ambulation. Therapy notes and staff observations showed the resident was independent and stable with walking, toileting, and transfers, but the care plan still contained conflicting interventions about needing assistance and unsteady balance. The DON stated the care plan should have been updated to show the resident was independent so staff would know the current care needs.
A resident with a stage IV pressure ulcer and dependence for transfers had an order to lie down after lunch to offload pressure from the wound, but the intervention was not included in the care plan. Staff observed the resident remaining in a wheelchair for hours after lunch, the resident said she had been waiting to be laid down, an NA said she did not see the intervention in the care plan, and the DON stated the care plan omission was her mistake.
A resident with multiple diagnoses including malnutrition and hemiplegia had a care plan for fluid volume deficit and hydration problems, but it was not revised after ED visits and a hospitalization for dehydration. The record did not reflect hospital discharge instructions for hourly fluids while awake, strict I&O, and water with repositioning, and staff confirmed the care plan lacked updated fluid intake interventions.
Care plans were not individualized for two residents who frequently left the facility or failed to sign out. One resident had multiple LOAs and several instances of leaving without notifying staff, while the other resident had dementia-related diagnoses, low elopement risk, and episodes of not returning as expected or being found off the unit after stepping out to smoke. Staff interviews confirmed residents were expected to notify nursing, sign out, and provide return times, but the records did not include clear care plan interventions or staff direction for these situations.
Failure to timely reassess fall interventions: A resident with mild cognition and a history of repeated falls had 23 falls, most unwitnessed, after admission. The care plan identified high fall risk and included basic safety interventions, but the first 10 falls had no post-fall assessment, the first assessment was delayed, and an IDT discussion about unsafe bedside urinal use was not followed by a documented care plan update before the resident continued to fall while using the urinal and toilet.
Failure to Update Care Plans With New Fall Interventions: The facility did not add resident-specific fall interventions to the comprehensive care plans for three residents with repeated falls. Although accident reports and IDT reviews identified new interventions for each resident, staff said the changes were often shared in report or email and the DON confirmed they were not incorporated into the care plans. The residents had histories of falls, impaired cognition or dementia-related diagnoses, and used mobility aids such as walkers or wheelchairs.
A resident’s care plan was not revised to match changing needs. The resident had Alzheimer’s disease, wounds, and a history of C-diff, but the care plan and TAR still reflected contact precautions and C-diff treatment after the infection had resolved, and the plan did not include the ordered Prevlon boot intervention for altered skin integrity. Staff and the DON acknowledged the resident should have been on EBP for wounds and that the orders and care plan should have been updated to reflect the current status.
Failure to update a resident’s care plan for end stage kidney disease. The resident had CKD, ESRD, HF, HTN, and intact cognition on MDS. Physician and nephrology notes documented discussion of palliative/hospice care and renal replacement therapy, and the resident declined dialysis. The current care plan only addressed bladder infection monitoring and did not reflect ESRD, the decision to remain comfortable, or what staff should monitor if kidney function failed.
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