Failure to develop and implement comprehensive care plans: one resident with an active UTI had no care plan interventions for the new diagnosis despite a physician order for antibiotics, and another resident’s oxygen therapy care plan and physician order called for 3 L via NC, but staff observed and confirmed the resident was receiving only 2 L. RN and DON interviews confirmed care plans were expected to guide staff care and include interventions for new diagnoses.
A resident with dependence on renal dialysis and moderately impaired cognition had an active order for dialysis three times weekly, but the care plan only listed the dialysis schedule and location. When routine transportation was unavailable on a holiday, the resident missed treatment, and staff confirmed no alternate transportation was arranged and the care plan did not include instructions for what to do if dialysis transport could not be provided.
A resident with CVA and multiple skin conditions, including a POA deep tissue injury, callus, MASD, and an unstageable pressure ulcer, did not have a comprehensive, person-centered care plan addressing wounds, skin impairment, repositioning, pressure-relieving devices, or treatment regimen. The MDS Nurse and DON both acknowledged that individualized wound care planning was expected and that no such care plan had been developed.
A resident with metastatic bone disease, a cervical fracture history, and moderate cognitive impairment did not have an individualized care plan for mechanical lift transfers. The care plan lacked directions for Hoyer lift use, sling type or size, and resident-specific transfer precautions, and staff confirmed there was no physician order or therapy documentation in the record to guide safe transfers.
Care plans were not fully developed or followed for several residents with identified needs. A resident with dementia was observed using a seat belt in a wheelchair without a care plan addressing it, and another resident with HF and moderate cognitive impairment had an active order for double portions but no dietary care plan. A cognitively intact resident with HF reported not receiving ordered pain medication, and two residents with DM had weekly nail care interventions that were not carried out, with nails observed to be excessively long and unclean.
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.
Care plans were not individualized to fully address assessed needs and ordered treatments for three residents. One resident with frequent pain had a care plan that did not direct staff on pain management during ADLs, turning, or repositioning despite reports of pain and a PRN opioid order. Another resident with hemiplegia, dementia, epilepsy, and poor safety awareness had a call light left out of reach and no documentation of monitoring for adverse effects from psychotropic and anticoagulant medications. A third resident with Parkinson’s disease, anxiety, and depression also had no documentation of monitoring for side effects from psychotropic and anxiolytic medications.
Failure to develop and implement comprehensive care plans for two residents. One resident with a Foley catheter and urinary retention did not have catheter care included in the care plan, and an MDS nurse confirmed it was only listed on aide tasks. Another resident with DM had a care plan for monthly and PRN nail care by the RN, but observations showed overgrown, jagged fingernails with debris underneath, and staff confirmed the plan was not being carried out.
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.
ADL Care Plans Not Implemented for Grooming Needs: Three residents had care plans that addressed ADL/personal hygiene needs, but observations showed unmet grooming needs. One resident had jagged, dirty fingernails, and two residents had visible facial hair that they said they wanted removed. An LPN and the MDS coordinator confirmed that clean, trimmed nails and removal of unwanted facial hair were part of personal hygiene and that the care plans were not being followed as written.
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