A resident had documented safety concerns related to leaving the facility without supervision, but the care plan was not updated to reflect that restriction. Nursing staff and the nursing manager did not add the needed intervention, even though progress notes and a physician note documented that the resident was not allowed to leave without supervision.
The facility failed to keep care plans current for three residents. One resident had ongoing behaviors such as refusing care, refusing meals, refusing the call light, and yelling out, but the care plan did not include those behaviors or related interventions. Another resident’s post-fall care plan did not include grippy strips recommended after the root cause was identified, and it did not reflect walker use observed in the halls. A third resident’s care plan did not include the use of colored lenses after staff documented that the trial helped with vision.
A resident was observed in bed with upper and lower bed rails in place, with open areas and spacing that could allow entrapment. Staff gave inconsistent explanations for why the rails were being used, and the care plan listed rail use as an intervention but did not show revised interventions for monitoring the resident’s ongoing bed rail use.
Two residents’ care plans did not reflect their POLST code status. One resident’s POLST indicated No CPR and the other indicated DNR, but both care plans documented Full code and included related interventions that did not match the POLST orders. Staff stated care plans were updated weekly, but could not explain why the code status was not reflected.
Care plan not revised for pneumonia treatment and precautions. A resident with COPD, dysphagia, MS, and a recent pneumonia infection developed emesis, nasal congestion, crackles, and a chest x-ray consistent with early pneumonia, leading to levofloxacin therapy. Staff said they tracked residents on antibiotics and updated care plans for infections, but the resident’s care plan was not revised to add pneumonia-related problems, goals, interventions, or updated transmission-based precautions.
A resident’s care plan was not revised to reflect current care needs. The resident was observed with heel protectors, and staff stated the resident had a pressure wound on the L heel. Record review showed an unstageable pressure ulcer on the L heel and a Stage II pressure ulcer on the coccyx, but the current care plan did not include these wounds or the use of heel protectors.
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.
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