Failure to Care Plan Resident Behaviors and Psychosocial Needs: A resident with ESRD and intact cognition had repeated verbal outbursts, cursing, refusal of care and meds, and missed dialysis, yet the care plan did not address his behaviors or psychosocial needs. Staff, including an LPN, CNA, SSD, ADON, and DON, confirmed no specific interventions were in place despite awareness of the resident’s abusive language and impact on care.
The facility failed to follow comprehensive care plans for two residents. One resident required a total lift for transfers, but staff used a sit-to-stand lift instead, despite the resident’s severe cognitive impairment, dependence with transfers, and diagnoses including dementia and bone density disorders. Another resident had an order for EBP, but an LPN did not wear a gown during gastrostomy tube medication administration and had contact with the resident’s linens while providing care.
Two residents receiving hemodialysis had care plan deficiencies related to ordered fluid restrictions. One resident’s dialysis care plan did not include a 1000 mL/day fluid restriction, while the other resident’s plan listed a 1200 cc restriction but staff did not track all fluids consumed, including water given during med pass and beverages brought in by family. Observations showed fluids present in the room, and the MDS nurse confirmed the care plan was not fully followed.
A facility failed to implement ADL care plan interventions for two residents related to facial hair grooming. Staff observations found chin hairs on both residents, and interviews confirmed CNAs were expected to assess and shave facial hair during bath or shower time. One resident had severe cognitive impairment and required assistance with personal hygiene, while the other had moderate cognitive deficits and required substantial assistance with personal hygiene. The residents’ care plans addressed personal hygiene and ADL support, but staff did not carry out the grooming care as planned.
Failure to implement shaving care plan interventions for two residents. One resident with stroke-related deficits and severe cognitive impairment had facial hair left on her chin despite a care plan task for facial hair removal, and she stated she wanted it shaved. Another resident with hemiplegia and hemiparesis was observed dry shaving himself with a razor despite a care plan requiring staff assistance with personal hygiene, including shaving; an LPN confirmed staff were expected to shave residents and that residents were not permitted to shave themselves.
Failure to care plan repeated bath refusals. A resident who was nonverbal but alert and communicated by head nods repeatedly refused bath care, and staff observed him refusing a bed bath. The comprehensive care plan did not address the ongoing refusals, had no measurable goals or specific interventions for hygiene refusal, and did not document the resident’s right to refuse treatment. Staff and the DON confirmed the resident often refused baths, the family had discussed the issue in care plan meetings, and the bath log showed multiple refusals along with inconsistent documentation.
A CNA failed to follow a resident's care plan for EBP during incontinent care by providing hands-on care without wearing a gown, despite the resident having a Stage IV sacral pressure injury and an active order for EBP. The CNA acknowledged the lapse, and the DON confirmed the resident's care plan was not followed.
A resident returned from the hospital with a Foley catheter in place, but the facility did not document physician orders, catheter care, monitoring, or a related care plan until weeks later. The resident had obstructive uropathy and reflux uropathy, and the DON confirmed the catheter was placed during the hospital stay and that the care plan was not developed timely despite the resident’s current condition.
Failure to Develop and Follow Nail Care ADL Care Plans: Two residents had unmet nail care needs. One resident with severe cognitive impairment had an ADL care plan that did not address nail care, and fingernails were observed long with jagged edges. Another resident with moderate cognitive impairment had a care plan directing staff to keep fingernails short, but fingernails were still observed about one inch long with jagged edges. The MDS Coordinator and DON confirmed the missing and unimplemented nail care interventions.
Care plan interventions were not implemented as written for three residents. One resident with CVA had long facial hair despite a care plan for shaving on shower days, another resident with MS had long jagged fingernails and no ordered hand/elbow contracture interventions in place, and a third resident with hemiplegia and encephalopathy had long jagged fingernails, poor oral hygiene, and no ordered left-hand splint in place. The DON and MDS Coordinator confirmed the care plans had been developed but staff failed to follow them.
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