Failure to care plan skin integrity risk for a resident with severe cognitive impairment, incontinence, and dependence for toileting and hygiene. The resident was identified as at risk for pressure ulcers, later developed skin abrasion and chaffing to the buttocks/ischium, yet the care plan did not include skin impairment.
A resident with dementia and severe cognitive impairment had an order for sodium chloride nebulizer treatments for congestion, and an LPN administered the treatment during observation. However, the resident's care plan did not include congestion or nebulizer use, and the LPN, MDS Coordinator, DON, and Administrator all acknowledged that no care plan addressing the treatment was in place.
A resident was readmitted after an unanticipated discharge with dx including UTI, malignant neoplasm of the duodenum, DM2, and COPD, but the facility only had a limited care plan covering nutrition and activities and did not develop a comprehensive person-centered plan addressing all needs. Staff also stated that a care planning meeting with the resident and/or representative had not been completed.
A resident with depression, atrial fibrillation, incontinence, pressure ulcer risk, and opioid pain medication use had an incomplete care plan. The care plan did not include focus areas or interventions for incontinence, skin integrity, or pain management, and the MDS coordinator and DON both confirmed it was incomplete.
Incomplete Comprehensive Care Plan for a Dependent Resident: A resident with severe cognitive impairment, HF, HTN, and a seizure disorder had a care plan that listed dependent toileting, transfers, and bed mobility, but did not explain how needs would be met. The DON stated the plan was not comprehensive because it failed to specify a 2-person assist for perineal care, transfers, and repositioning with a draw sheet for a 250-lb resident.
A facility failed to develop complete person-centered care plans for a resident on hospice and another resident receiving respiratory support. The hospice resident’s care plan lacked a hospice focus, goal, and interventions, while the respiratory resident’s plan omitted NIV and oxygen therapy despite orders and observations showing use of both. MDS staff and the DON stated care plans should reflect these needs, but the plans were not accurately maintained.
A resident with a dx of dementia did not have that condition care planned. Record review showed the dx on the medical diagnoses list and a care plan that listed dementia as a diagnosis but had not care planned it. An RN confirmed the dementia had not been care planned, and the administrator stated it was expected for an RN to care plan a resident’s dementia dx.
A resident with dementia and severely impaired cognition was identified as at risk for wandering and elopement, but the care plan did not include elopement interventions despite nursing notes showing frequent wandering and aimless ambulation. The resident later left the facility and walked to a family member’s home, where a forehead abrasion was noted. Staff stated the resident had wandering behaviors since admission and that the care plan should have addressed wandering and elopement.
A facility failed to develop comprehensive care plans for two residents. One resident had severe cognitive impairment, hospice services, and limited ROM/contracture, but the current care plan did not include hospice or the contracture/ROM needs. Another resident with severe cognitive impairment was observed repeatedly wandering into other residents’ rooms and telling them to leave, yet the care plan did not address the wandering or room-entry behaviors.
Elopement Risk Not Addressed in Care Plan: A resident with schizophrenia and dementia had documented wandering and exit-seeking behaviors, but the care plan lacked wandering/elopement interventions before the resident exited through a window and was found in a staff member’s truck. Staff interviews confirmed the resident had been trying doors, entering codes, and triggering alarms before the incident, while the DON and MDS Coordinator were unclear on how the elopement risk assessment was used and did not incorporate staff input into care planning.
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