A resident with a history of TBI, hemiplegia, and bipolar disorder repeatedly complained that a specific CNA was slow to respond, rude, and problematic during cares. Grievance forms documented that the resident requested the CNA not provide care, agreed to 2-hour rounding in pairs, and that cares in pairs would be implemented for night cares, with the form indicating the care plan was updated. However, review of the Comprehensive Care Plan showed no revisions since the prior year and no interventions reflecting paired staffing or altered care approaches related to these grievances. The ADM acknowledged the CCP was not revised, treated the issue as a personnel matter rather than a care-planning issue, and progress notes contained no documentation of the staffing changes, while the resident reported that the CNA continued to enter the room and that grievances did not result in effective changes.
A resident with DM who received insulin did not have a comprehensive care plan that addressed diabetes care. The care plan lacked a focus area for DM and did not identify monitoring for signs of high or low blood sugar, and the DON confirmed the omission.
Failure to Include Ordered Fluid Restrictions in Care Plans: Two residents had physician-ordered fluid restrictions that were not included in their CCPs. One resident had a 1.5 L daily fluid restriction, and another resident with HTN, a BIMS score of 11, and supervision needs had an order for a fluid restriction related to HTN, but neither care plan addressed the nutritional intervention. The MDS Coordinator confirmed the omissions.
A CCP failed to include a resident’s stated discharge goal to return home after a stage 3 pressure ulcer healed, even though the resident and spouse both identified that plan. Another resident’s CCP did not match the current pureed diet order and also omitted the resident’s antipsychotic medication use and monitoring needs, despite MDS, physician orders, EMAR, and staff interviews confirming the diet change and ongoing Risperidone administration.
A facility failed to include measurable, resident-specific care plan details for ADLs and respiratory equipment needs for three residents. One resident with severe cognitive impairment and extensive ADL dependence had no ADL care plan, another resident with severe cognitive impairment and transfer/toileting needs had no care plan focus for transfers, positioning, or ADLs, and a third resident with respiratory failure and OSA had a BiPAP order but the care plan did not address the PAP machine specifics.
Failure to include a resident’s activity preferences in the care plan. Record review showed the resident’s MDS identified important preferences such as being around pets, keeping up with the news, going outside for fresh air, and participating in religious services, but the care plan had no focus area or goals related to those preferences. The DON confirmed the care plan lacked a section for activities preferences and said the MDS Coordinator was responsible for updating it.
Failure to implement a comprehensive nutrition care plan. A resident with severe cognitive impairment, extensive assistance needs, and about 50% meal intake had a baseline plan for a mechanical soft diet and eating assistance, but the comprehensive care plan did not include altered nutrition. The RD confirmed the nutrition care plan should have been in place earlier but was not implemented until later.
A facility failed to keep care plans comprehensive for 3 residents. One resident with dementia and anxiety had repeated behaviors such as yelling, agitation, repeated call light use, and nighttime distress, but the care plan did not address those needs. Another resident with a right BKA wanted a prosthesis and had daily-life limitations, yet the care plan only noted the amputation without goals or interventions. A third resident with MDD had antidepressant therapy and depression documented, but the care plan had no related diagnosis or interventions.
Care plans for two residents were not comprehensive. One resident had ongoing constipation with repeated PRN bowel med use, but the care plan did not include constipation or related interventions. Another resident had depression documented on the MDS and was receiving sertraline, but the care plan did not reflect the diagnosis or any interventions tied to the antidepressant treatment.
Missing Care Plans for Prophylactic Antibiotic and Anticoagulant Use: The facility failed to develop CCPs for a resident receiving prophylactic antibiotics and another resident receiving an anticoagulant. One resident had UTI-related diagnoses, a foley catheter, hospice antibiotic orders, and Macrobid for UTI prevention, but the CCP did not address antibiotic prophylaxis. Another resident had atrial fibrillation and stroke history, was ordered Apixaban, and had orders to monitor for bleeding, but the CCP did not address anticoagulant use or bleeding risk; the DON confirmed both omissions.
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