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.
Failure to implement fall care plan interventions for a resident with severe cognitive impairment and high fall risk. The resident had multiple recent falls, bruising and a knot on the head/neck area, and was observed wearing non-grip socks. Surveyors found missing fall precautions in the room, including no sign by the bed, no tape on the call light, no floor grip tape, and the bed not in the lowest position; the ADON also stated therapy note interventions were not added to the care plan.
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 resident with acute respiratory failure, COPD, and HTN was observed resting in bed with oxygen at 3 L via NC, but the care plan did not address oxygen use despite a physician order for continuous oxygen at 2 to 3 L via NC and tubing changes on Wednesdays. The MDS coordinator stated oxygen use should have been included in the care plan but was missed.
A resident with OSA had a CPAP order and was observed using the CPAP, but the care plan did not include CPAP-related interventions or details. Two cognitively intact residents were current tobacco users and were observed smoking or keeping smoking materials in their rooms, yet their care plans did not include smoking-related goals or interventions. Staff interviews confirmed awareness of the CPAP use and smoking status, but the care plans did not reflect these needs.
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.
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