Incomplete Care Plan for Resident with Schizophrenia and Psychotropic Medication Use: A resident admitted with Bipolar Disorder and Schizophrenia had an MDS showing use of an antipsychotic, antianxiety, and antidepressant medication, but the CCP only addressed antipsychotic-related adverse reaction risk. The care plan did not address the resident’s Schizophrenia, antidepressant use, or anti-anxiety medication needs, and the ADON and DON confirmed the plan was not comprehensively completed.
A resident with stroke and morbid obesity had an order for oxygen at 1-2 L/min via NC, but the comprehensive care plan did not include any oxygen focus area or interventions. Staff observations showed the oxygen concentrator on while the NC was lying on the bed sheet, and the resident and DON both confirmed the resident used oxygen at night; the DON later acknowledged the oxygen was not on the care plan.
A facility failed to develop and implement comprehensive, person-centered care plans with measurable goals and timeframes for 2 residents. One resident’s plan listed multiple psychotropic and other medications with broad monitoring language, but no specific measurable objectives or timelines for AIMS checks or gradual dose reductions, and staff confirmed the goals were not objective or resident-specific. Another resident’s care plan was not updated for new pain medication, Lasix, failure to thrive, CHF, edema, and worsening skin breakdown/infection, and the ADON confirmed the goals were not measurable or person-centered.
Failure to care plan respiratory needs and neck positioning. One resident with moderate cognitive impairment, a hx of COVID-19, OSA, and anxiety had oxygen therapy and nebulizer treatments in use, but the care plan did not include a respiratory focus area. Another resident with chronic pain, osteoporosis, and kyphosis was repeatedly observed with the head and neck leaning to one side, yet the care plan did not address neck positioning or interventions to assist with proper positioning.
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.
Incomplete Comprehensive Care Plans: The facility failed to include all care needs identified in the MDS in the comprehensive care plans for two residents. One resident had a history of UTI, confusion, saturated briefs, and antibiotic treatment, but the care plan did not address toileting needs, UTI risk, or monitoring/prevention interventions. Another resident had diabetes and edema, with insulin orders and ongoing swelling, but the care plan did not include diabetes or edema as focus areas.
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.
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