A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
A resident’s CCP was not revised to reflect the correct advance directive status after Hospice admission and a DNR order were obtained. The resident had a BIMS score of 14, required extensive to total ADL assistance, and was receiving Hospice services, but the CCP still listed full code and advance directive entries showing no change. The SW confirmed the CCP should have been updated to no code after the facility received the DNR paperwork and Hospice documents.
A resident with moderate cognitive impairment and diagnoses including dementia, frontal lobe/executive function deficit, depression, and anxiety was repeatedly identified as high elopement risk, but the care plan did not include an elopement risk focus or any interventions. Staff confirmed the resident was on the elopement list, an alarm was attached to the room door, and the ADON acknowledged the care plan update had not been completed.
A resident with severe cognitive impairment, dementia, immobility, and total dependence for many ADLs developed multiple abrasion and scabbed areas on both shins. Although the CCP identified risk for skin breakdown and included general measures, it did not include the specific interventions used for the shin wounds, such as Betadine treatment and sheepskin pads/wraps during transfers, and the RN and administrator confirmed the CCP lacked specific wound-related interventions.
The facility failed to complete and update care plans as required. One resident with diabetes, cancer, ESRD, and significant weight loss had a care plan that did not address malnutrition or weight-loss interventions, despite MDS and RD findings showing severe nutritional decline. Another resident with CHF, stroke, impaired hearing, and no speech had a care plan that did not show the legal guardian/sister was invited to care plan meetings, and the Social Services Director confirmed there was no documentation of guardian participation.
Care plans were not kept current for two residents, including one whose code status changed from full code to DNR and another whose PASRR showed SMI but whose MDS and care plan did not reflect it. The facility also could not show that a resident’s representative was able to participate in care plan meetings, and the family reported limited involvement over years of care. The DON, MDS Coordinator, SSD, and ADM all confirmed gaps in documentation and awareness of the missing or inaccurate care plan information.
Care plans were not complete or accurate for residents with MDROs and psychotropic use. Two residents had VRE or MRSA and needed assistance with high-contact care, but their care plans did not include EBP despite posted signage outside their rooms. Another resident had dementia, was receiving Haloperidol, and had repeated administrations documented on the MAR, but the care plan did not identify the antipsychotic medication. The MDS Coordinator and DON confirmed the omissions.
Care plan not updated after antidepressant change. A resident’s care plan still listed citalopram and related monitoring interventions even after the provider discontinued the medication due to possible contribution to tremors. The DON confirmed the care plan had not been revised to reflect the change.
A resident with multiple medical conditions and intact cognition required total staff assistance and had clearly communicated preferences for morning and evening routines during a care plan conference attended by their spouse. Despite this, the care plan was not updated to include the resident's preferred times for getting up and going to bed, as confirmed by the DON.
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