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.
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.
Failure to Care Plan for Camera Monitoring Device: A resident with acute respiratory failure with hypoxia, cognitive changes following CVA, and chronic pain syndrome had a camera installed in the room at family request, with the device actively recording audio and video and a roommate present. The DON confirmed the family continuously monitored the feed, but the resident's care plan did not include the electronic communication device, despite an earlier care conference about the monitoring device and a posted sign indicating recording was in use.
Incomplete Person-Centered Care Plans: The facility failed to develop person-centered care plans based on comprehensive assessments for two residents. One resident with generalized weakness, cognitive communication deficit, and major depressive disorder was documented as incontinent of bowel and bladder and dependent for toileting, but the care plan did not address incontinence. Another resident with dementia, generalized weakness, and complete loss of teeth required help with bathing and oral care, but the care plan did not include bathing, shaving, or denture care. The DON confirmed the missing care plan items.
A resident with bilateral lower extremity pain, onychomycosis, cellulitis of the right big toe, and morbid obesity had extensive flaky skin dryness with visible scaling on both lower extremities. Although an order directed staff to apply antifungal cream daily and PRN for dryness, the medical record lacked evidence of a care plan for the skin condition. The DON confirmed a corresponding care plan should have been in place.
A resident with anxiety disorder and schizophrenia did not have non-pharmacological interventions care planned or ordered to address behavioral symptoms tied to psychotropic use, and the DON stated such interventions were not necessary. Another resident with dementia and COPD was documented as able to smoke independently, but the smoking evaluation had an incomplete IDT sign-off, and cigarettes and a disposable lighter were found in the resident's room.
A resident with COPD, pleural effusion, hypothyroidism, and contact isolation status was observed enjoying puzzles but had not attended activities and was unaware of what the facility offered. The medical record lacked an activity care plan with specific interventions and measurable goals, and an Activity Aide and the MDS Director were unaware of who was responsible for completing the plan, which should have been done within 14 days of admission.
A resident who tested positive for COVID-19 had Droplet Precautions in place, but the clinical record lacked a care plan for the infection or precautions. Another resident with a chronic stage IV coccyx pressure ulcer had an order for wound care every other day, but the scheduled dressing change was not documented as completed, and the DON and RCM confirmed the treatment was not recorded in the chart.
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