Staff failed to develop and implement person-centered care plans for three residents with cognitive impairment and behavior-related needs. The plans did not include resident-specific interventions for wandering, agitation, exit seeking, inappropriate room entry, or other documented behaviors, and staff interviews showed they did not know the care plan directions for these residents.
Staff failed to develop a comprehensive, person-centered care plan for a resident who was cognitively intact and had diagnoses including anxiety, cardiac arrhythmia, vitamin deficiency, and pain. The only documented care plan focus was smoking, noting that the resident could smoke unsupervised and should avoid injury from unsafe smoking practices, with no care plan entries for ADLs, behaviors, or medical diagnoses. The administrator and MDS Coordinator acknowledged that the care plan should have been more complete and reported that the MDS nurse had been pulled to work as an RN on the floor, contributing to delays and backlogs in care plan development.
Failure to include blood thinner interventions in care plans: Two residents had orders for anticoagulants, but their care plans did not address the medications or include resident-specific, person-centered interventions. One resident had CKD, ecchymoses, cerebrovascular disease, TIA history, and prior cerebral infarction and was receiving apixaban for AFib; the other had COPD and paroxysmal AFib and was receiving rivaroxaban. The ADON, Administrator, and DON stated that residents on blood thinners should be addressed in the care plan with specific interventions.
The facility failed to develop individualized care plans that reflected the current needs of four residents. Care plans did not include key interventions for a suprapubic catheter, ileostomy, anticoagulant therapy with PT/INR monitoring, a cardiac pacemaker, dementia care, PICC line care, antibiotics, respiratory support with BiPAP and oxygen, DM management, and blood thinner therapy. The DON, Nurse Manager, and Administrator stated that care plans should accurately reflect residents’ current conditions and be revised with changes.
The facility failed to include specific goals and interventions in the care plans for two residents. One resident with dementia, bipolar disorder, MDD, asthma, and a history of self-harm/suicide attempts had no care plan details for those conditions, and staff interviewed were unaware of the resident’s history or interventions. Another resident with obstructive sleep apnea had no care plan address for CPAP use at bedtime.
The facility failed to develop comprehensive person-centered care plans for two residents. One resident’s care plan did not include the resident’s goal to return to the community, despite being cognitively intact and stating that goal during interview. Another resident’s care plan did not address DNR/code status, even though the face sheet and physician orders reflected DNR and the DON stated care plans should address code status.
A resident with severe cognitive impairment, diabetes, atrial fibrillation, reduced mobility, and a history of falls had an incomplete care plan. The plan addressed oxygen use but did not include insulin monitoring, anticoagulant monitoring for Eliquis, high fall-risk interventions, or toileting needs, even though the resident was always incontinent and required extensive assistance with ADLs.
Failure to Individualize Care Plans for PTSD and Dementia: The facility did not develop complete, person-centered care plans for residents with PTSD and dementia. Care plans for several residents failed to address diagnoses, resident-specific triggers, or individualized interventions, and one resident with PTSD stated that anger was a trigger. The MDS Coordinator said care plans should reflect individualized needs, while the DON, Administrator, and Social Worker stated the trauma assessments were broad and did not provide enough detail about residents’ trauma or triggers.
Care plans were not kept accurate for residents with changing needs. One resident had worsening anxiety, severe depression, weight loss, confusion, wandering, suicidal statements, and increased help needed with eating, but these changes were not reflected in the care plan. Other residents had repeated falls and fall-related injuries, yet the care plans did not include recent fall interventions such as fall mats or other updated safety measures.
The facility failed to keep resident care plans current and individualized for several residents. One resident with MDD, Bipolar Disorder, and Anxiety Disorder had no specific care plans for those diagnoses, another resident admitted for knee replacement lacked pain goals and detailed pain interventions, and a resident with dementia and depression had documented agitation, refusal of care, and physical aggression without a behavioral care plan or clear depression-related symptoms and interventions. Staff and the DON stated care plans should be specific, up to date, and reflect each resident’s current status.
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