A resident with identified fall risk had a care plan intervention to use a fall mat, but the mat was observed stored under the bed while the resident was lying in bed. An RN confirmed the mat should have been placed on the floor next to the bed, and the DON acknowledged that the recommended use was floor placement when the resident was in bed and that the care plan was not person-centered or specific about this recommendation.
Surveyors found that two residents with documented unstageable pressure ulcers and identified needs for pressure ulcer care on their admission MDS and Care Area Assessments did not have corresponding pressure ulcer or wound care interventions included in their comprehensive care plans. One resident’s care plan lacked any pressure ulcer component despite multiple unstageable and deep tissue injuries noted on admission, and another resident’s care plan omitted pressure ulcer care until it was added at a later date. The DON acknowledged that the comprehensive care plans for these residents did not address their pressure ulcers or wound care needs, contrary to facility expectations.
Surveyors found that care plans for two residents were not updated to reflect current medical needs. One resident with COPD and other chronic conditions had a physician order for PRN oxygen at 2 L/min via nasal cannula, but this oxygen use was not included in the care plan, as confirmed by the DON. Another resident with multiple neurologic and urologic diagnoses, as well as wasting disease and sarcopenia, was observed with red, swollen ankles and legs; a physician note documented ankle edema, yet the care plan did not address this condition, which the DON acknowledged was missing.
Surveyors found that the facility failed to maintain comprehensive, person-centered care plans for two residents. One resident, at risk for PUs and later found to have a sacral wound with physician-ordered treatment, did not have wound care interventions added to the care plan for approximately two months after the wound was identified. Another resident with documented respiratory failure and pulmonary edema had a care plan that omitted O2 use as an intervention and lacked any problem, goal, or interventions related to hearing limitations or hearing aids. The DON confirmed these omissions and stated that hearing difficulties and O2 use should have been included in the residents’ care plans.
A resident was admitted with multiple diagnoses, including osteoporosis, epileptic spasms, GERD, hemiplegia/hemiparesis after cerebral infarction, insomnia, recurrent major depressive disorder, dementia, and a need for ADL assistance. Review of the care plan showed it only addressed elopement risk, dementia-related nutritional risk, and behavior changes after stroke, while omitting other significant conditions such as epileptic spasms, GERD, insomnia, depression, and ADL needs. During interview, the DON confirmed these omissions and acknowledged that the care plan was not person-centered and did not reflect the resident’s overall condition.
A resident was receiving supplemental O2 via nasal cannula and had a floor mat placed beside the bed, but the facility failed to develop and implement a comprehensive care plan addressing these interventions. Record review showed an active O2 order without corresponding care plan interventions, and there was no order for the floor mat. Observations confirmed the resident’s use of O2 and the floor mat, and both the ADON and DON acknowledged that these should have been included in the care plan but were not.
Surveyors found that the facility did not develop comprehensive care plans for three residents. One resident with an MDRO and on Modified Protective Environment Precautions had no MDRO-related or precaution interventions in the care plan despite an infection alert and signage at the room. Another resident with physician-ordered side rails used them for mobility and repositioning, but the care plan did not address side rail use. A third resident with COPD and other conditions used a CPAP machine nightly, yet the care plan contained no CPAP-related interventions. The DON and IPC acknowledged these omissions.
A resident with a left leg fracture and surgical wounds had physician orders and assessments indicating the need for wound care, but the care plan did not include the required interventions for wound healing. The DON confirmed that while the wounds were noted in the care plan, the specific interventions were not documented as expected.
A resident with multiple cardiovascular conditions was prescribed Clopidogrel, an antiplatelet, as documented in physician orders and the MDS, but the care plan incorrectly identified the resident as receiving anticoagulant therapy and at risk from blood-thinning medications. During observation, the resident had bruising on both hands and reported being on an anticoagulant, and the DON later confirmed that the medical record did not show an anticoagulant order and that the resident had been care planned for the wrong type of medication.
Surveyors found that the facility failed to complete accurate and timely baseline care plans for four newly admitted residents. One resident with metabolic encephalopathy and end-stage renal disease had missing Social Services, Rehab, and Activities information and an incorrect regular diet order. Another resident with multiple fractures and mental health diagnoses had a baseline care plan that was not completed until nearly two weeks after admission. A third resident with a sacral fracture, HTN, osteoarthritis, and urinary retention had a baseline care plan finalized more than two weeks post-admission. A fourth resident with complex conditions, including chronic respiratory failure, vertebral fractures, gastrostomy status, and long-term anticoagulant use, had a baseline care plan that omitted current smoking status, anticoagulant therapy, and all nutritional information despite use of a feeding tube.
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