A resident with a history of heel pressure injuries was observed in bed without the ordered foam heel boots, despite a care plan intervention for bilateral heel protection. In a separate case, a resident receiving Apixaban had a care plan that did not identify the anticoagulant or include measurable goals and monitoring interventions for bleeding-related adverse effects.
A resident with an indwelling catheter was observed sitting in a wheelchair with the catheter tubing coming out from under her pajama pants. Staff stated the catheter was being continued due to incontinence and because the resident wanted it for convenience, but the resident’s care plan did not include catheter care interventions.
Incomplete Care Plan for Pressure Ulcer: A resident with a Stage IV coccyx pressure ulcer present on admission had a care plan that did not address the pressure ulcer until months after admission. During observation, the wound was nearly healed with no drainage or odor, and an NF applied a small hydrocolloid dressing, while the care plan only listed impaired skin integrity risk and incorrectly described the coccyx wound as Stage III.
The facility failed to complete person-centered care plans for a resident with an indwelling urinary catheter and for two residents with PTSD. A resident with a catheter had a care plan for neurogenic bladder and urinary infection prevention, but it did not include EBP for infection control. Two residents with PTSD reported anxiety, claustrophobia, and other triggers, yet their care plans did not identify PTSD triggers or include interventions to help staff manage behaviors, anxiety, or stress.
Failure to include individualized bathing preferences in the care plan for a resident with an ADL self-care deficit. The resident stated she needed assistance with showers and was upset that she did not receive showers twice weekly as preferred, saying she did not feel clean when showers were missed. The care plan addressed bathing in general but did not include the resident’s preferred shower frequency or specific bathing services needed to meet her hygiene needs, and staff gave inconsistent responses about who was responsible for care plan completion and updates.
Incomplete and inaccurate resident care plans were identified for 4 residents when MDS/CAA findings did not match the documented care plans. The care plans missed or misstated ADL assistance levels such as bathing, oral hygiene, and tub/shower transfers, and one resident’s pressure injury risk and related interventions were not included. Staff stated care plans were updated by the IDT and nurses, but also acknowledged some ADLs may have been missed.
Failure to care plan right-hand ROM decline: A resident was observed with the right hand flexed into the palm and unable to fully open the fist, and later was spoon-fed at breakfast without using the hands to assist. Staff reported the resident had not been able to eat with her hands since returning from the hospital and had declined after a recent hospitalization. The care plan did not identify the ROM limitation or include interventions for ROM, positioning, or therapy evaluation, and there was no documented revision to reflect the change in function.
Incomplete care planning affected side rails, EBP, and nutrition management. Two residents had side rails in place, but their care plans did not identify the rails or include related interventions, risks, or monitoring. Another resident with a catheter had no EBP signage or PPE observed and no care plan focus for EBP. A resident with unplanned weight loss had a diet order for the highest calorie supplement, but staff were unaware of the order and the supplement had not been given.
A resident with PTSD from the Vietnam and Kuwait War reported memories and flashbacks, with loud noises and people walking behind him identified as triggers. He stated staff had not asked about his triggers. Review of the care plan showed behavioral monitoring and guidance not to pressure the resident if he did not want to talk about stress, but it did not address his triggers or interventions.
Incomplete care planning for splint use and dementia: A resident with left-sided hemiplegia and a near contracture of the left wrist was observed with the left hand flexed, while OT records noted prior splint use, increased tightness, and a new splint to be ordered; however, the care plan did not include the hand splint intervention. Another resident with a documented dementia diagnosis showed confusion and difficulty using a radio and TV, but the care plan did not include dementia or related interventions.
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