A facility failed to keep care plans updated for three residents with changed needs. One resident with a suprapubic catheter had no care plan focus for catheter care, catheter changes, or infection monitoring; another resident taking mirtazapine for depression had no care plan details for the medication, nonpharmacologic interventions, depression symptoms, or adverse effects; and a third resident receiving comfort care had no care plan interventions for end-of-life needs, including fear of dying, terminal restlessness, positioning, reorientation, or family education.
Care plans were not updated for two residents after Foley catheters were placed, with one resident's plan still focused on urinary incontinence and another resident's catheter interventions not appearing until months after the MDS showed an indwelling catheter. The facility also did not involve a cognitively intact resident's family in the care conference, despite the resident stating he wanted family participation and a family member reporting the facility never called for the meeting.
Care plans were not accurately updated for two residents. One resident with DM, ESRD on HD, A-fib, CHF, CVA, and toe amputations had a care plan that still referenced a fistula/graft/catheter and outdated diet orders, and it did not include dialysis clinic details, transport, or treatment times. Another resident used a seatbelt in an electric wheelchair for safety, but the care plan did not include interventions related to that preference.
Failure to Position Resident Safely for Medications: A resident was observed lying flat with his head kinked forward when taking morning meds. He asked an staff member to adjust his head so he would not choke, but the HOB was raised too quickly, the resident winced, and the staff member did not reposition him again or provide education about swallowing at a 30-degree angle. The resident coughed and spat out pudding used with the medication, and the care plan did not document the need to sit him up for meals or med pass.
A resident’s comprehensive care plan was not updated to match his current tobacco use and related MD orders. Staff observed [NAME] tobacco pouches at the bedside, but interviews showed confusion about whether the resident was using tobacco or nicotine replacement products. The care plan still referenced nicotine pouches in a tobacco-free environment, while staff later verified the pouches were a tobacco product and stated the care plan and orders did not reflect that.
A resident with unspecified dementia and behavioral disturbance had a care plan that was not updated after a physical incident in which he rubbed another resident’s shoulders and arms from behind and kissed her on the cheek in the dining room. The record showed the other resident lacked sufficient cognition to consent, and the resident’s comprehensive care plan did not include updated monitoring for physical behaviors toward other residents after the event.
Care plans were not properly updated for a resident who communicated by cell phone, a resident whose representative was not invited or involved in care planning, and two residents with smoking-related needs. Staff observed one resident texting as the main communication method, but the care plan did not direct staff on how to communicate with her. A resident representative said he had never been invited to care plan meetings, and there was no documentation of participation or an explanation why it was not practicable. Two residents who smoked also had incomplete care plans, including missing oxygen and lighter safety interventions for one resident and a missing smoking apron intervention for another.
Care plan goals and interventions were not updated for two residents with changed conditions. One resident had dementia behaviors and multiple PRN psychotropic orders, including PRN Ativan and ABH gel, but the care plan only listed monitoring for side effects and effectiveness, and staff could not explain the dosing parameters or limits. Another resident had severe wt loss with a 17% loss over 6 months, yet staff said the resident had not been identified for wt loss monitoring or an IDT update, and the care plan still reflected a goal to maintain wt at 169 lbs.
A resident eloped from the facility without staff knowledge by exiting through an alarmed door that had been deactivated by a vendor. Following the incident, staff reported that the care plan would be updated after an IDT review, and facility documentation stated the plan would reflect a need for closer monitoring and supervision near exits. However, the actual care plan revision only included adding the resident to an elopement binder, providing education about not leaving without assistance, encouraging use of an enclosed patio, and general wandering/elopement interventions, without specifying closer supervision at exits. This failed to align with the facility’s own elopement policy requiring that risk-related interventions be incorporated into the care plan and communicated to staff.
The facility did not update the comprehensive care plans for two residents after changing their incontinence products from disposable to reusable liners. Both residents expressed dissatisfaction with the new products, reporting increased accidents, but their care plans were not revised to reflect the new interventions, education provided, or the residents' concerns.
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