Incomplete Care Plans for Medications, Foley Catheter Care, and Pain The facility failed to develop resident-specific care plans for high-risk meds, Foley catheter care, and pain management for three residents. One resident had orders for spironolactone, methadone, and PRN hydromorphone, but no care plan addressed monitoring for side effects. Another resident had a Foley catheter and an order for routine site cleansing, yet the care plan lacked catheter care interventions and goals. A third resident had chronic pain treated with oxycodone, but the pain care plan contained blank SPECIFY fields and was not individualized.
Care plan not implemented for aggression and wound care: A resident with a history of physical and verbal aggression had a care plan that called for staff to analyze triggers and document de-escalation methods, but the DON stated the record and treatment plan did not include methods staff would use to de-escalate the behaviors, and a later aggressive episode was not accurately captured on the behavior task. Separately, a resident with a right heel wound had ordered wound care documented as completed on the TAR, but the floor nurse and wound care LPN confirmed the dressing was not in place and the wound care had not actually been performed by the assigned nurse.
A resident with schizophrenia and bipolar disorder displayed repeated inappropriate sexual behaviors, including sexual comments to an LPN, exposure of genitals at the nursing station, and other boundary-crossing actions. Psychiatry recommended monitoring inappropriate sexual behaviors, but the record lacked evidence that this target behavior was incorporated into the care plan when the incidents occurred. Social Services addressed boundaries with the resident, yet the comprehensive person-centered care plan was not created until later after another allegation was reported.
A resident with severely impaired cognition and diagnoses including metabolic encephalopathy and anxiety had repeated sexual and physical intrusive behaviors involving both female residents and staff. Although the care plan included an initial incident and a revision date was entered, the interventions were not revised or updated, and the ED and LPN confirmed that additional interventions identified for monitoring and redirection were not added to the care plan.
A resident with chronic pain had a care plan that did not include non-pharmacological pain interventions, and staff documented pain without recorded interventions. Another resident with ESRD and dialysis refusals had a care plan that lacked refusal-related interventions and education for missed treatments. Additional residents had care plans missing PTSD/trauma-specific interventions, oxygen therapy and respiratory monitoring details, and ordered psychotherapy for adjustment disorder with depressed mood.
A resident with MS and polyneuropathy developed new occasional urinary incontinence after previously being continent, but the care plan did not include a focused care area or interventions to address the change. The resident reported not recalling staff prompting toileting at timed intervals, and the DON confirmed the care plan lacked urinary incontinence interventions and that the facility did not have a bladder training or retraining policy.
A resident with psychosis, schizophrenia, and major depressive disorder, initially assessed as not wandering and with moderately impaired cognition, later wandered into another resident’s room and was pushed to the floor, sustaining a bleeding nose, a skin tear, and forehead redness. Following this incident, the medical record did not contain a care plan addressing the new wandering behavior, despite the DON stating that the assigned nurse was responsible for initiating such a plan and describing typical wandering interventions, and despite facility policy requiring ongoing assessment and revision of person-centered care plans as resident conditions change.
Failure to Care Plan Chemotherapy Medication: A resident with MDS received Inqovi, a chemotherapeutic medication, but the comprehensive care plan did not include the medication, administration precautions, side effects, lab monitoring, masking precautions, or handling of bodily fluids/excretions. The MAR showed the drug was administered routinely, and an oncology email outlined detailed directions for empty-stomach dosing, double-gloving, locked storage, weekly CBC/CMP monitoring, and transfusion thresholds, yet these items were not reflected in the care plan.
A resident admitted with ALS had an activities assessment documenting preferences such as bingo, social events, being outside, one-to-one visits, movies, an iPad, and audiobooks, and was cognitively intact with a BIMS of 15/15. However, the comprehensive care plan contained no activities focus, goal, or interventions. The AD stated an Activity Care Plan should have been developed.
Failure to Implement Foley Catheter Care Plan: A resident with a Foley catheter, prostate cancer, BPH, and UTI had a care plan calling for catheter care twice daily, infection monitoring, and urine assessment, but staff did not implement the planned interventions. The resident reported the urinary bag had not been emptied that morning, the catheter had not been replaced since admission, and the insertion site was not being cleansed routinely; a family member said they were providing the resident’s cleaning needs because staff care was inconsistent. The medical record lacked evidence of physician care orders being entered or routine Foley care being documented, and the DON confirmed the care plan interventions were not implemented because the orders were not in the chart.
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