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.
Missed Care Conferences and Incomplete Person-Centered Care Planning: The facility failed to complete timely person-centered care conferences for a resident with intact cognition and multiple chronic diagnoses, including schizoaffective disorder, cancer, heart disease, diabetes, seizures, anxiety, depression, bipolar disorder, and lung disease. The EMR showed MDS assessments on the schedule, but care conference documentation was limited and did not show whether the resident was invited or attended. The SS-D, RN-C, and DON all acknowledged that care conferences were not completed in line with the MDS cycle for several assessments, and the resident stated not remembering a meeting to discuss care.
Missed Quarterly Care Conference and Resident Participation: A resident who was cognitively intact and had HTN, arthritis, and schizophrenia did not have documented routine care conferences at the expected quarterly interval. The EMR showed care conferences were documented, but there was no evidence of one between two documented meetings, and the resident stated she had not been invited to any care meetings over the past year. The LSW and Admin both confirmed the lack of documentation and stated residents should be included when able.
Care Plan Not Revised for Resident No Longer Considered an Elopement Risk: A resident with Alzheimer’s disease and severe cognitive impairment lived on a secured memory care unit and was dependent for all ADLs. The resident’s elopement risk assessment showed low risk, but the care plan still listed high elopement risk and wandering behaviors. Staff stated the resident was no longer actively exit seeking, and the DON and corporate nurse agreed the resident was no longer an elopement risk, yet the care plan had not been revised to reflect the change.
Missed Care Conference Participation: A resident with intact cognition was not given the opportunity to attend and participate in a care conference. Staff confirmed care conferences were expected after MDS assessments and significant changes, but the resident’s record showed no conference documented for several months, and the family member reported the last conference had been months earlier.
Care plans were not updated to reflect changed resident conditions, preferences, and interventions. One resident's plan still showed hospice and wound-based EBP after hospice ended and the wound healed, another still listed Influenza A after the illness had resolved, and a third did not include behavior interventions such as a door chime and bookshelf sticker or updated dining preferences. Two residents with family-requested cameras also had care plans that omitted the camera use, rationale, and related monitoring details.
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