Care Plan Not Updated for Wandering Risk Increase A resident with dementia, delirium, head injury, and moderate cognitive impairment had a care plan that noted impaired cognition but no wandering interventions. After a wandering risk scale changed from low to high risk and notes documented pacing, confusion, wandering, and an exit from the facility that required staff intervention, the care plan was not updated to include wandering or elopement risk interventions.
A resident with a UTI history and neuromuscular bladder dysfunction had an indwelling catheter ordered for recurrent UTIs and poor bladder emptying, with monthly and PRN changes ordered. The resident was observed with a catheter bag attached to the wheelchair, but the care plan did not document the catheter or the care required. The DON stated catheter care should have been added to the care plan.
A resident with COPD, intact cognition, and PRN oxygen orders was found to have numerous small portable oxygen cylinders stored in a closet, some standing and some tipped over on the floor, with at least two cylinders confirmed full. The resident reported bringing these cylinders from a family member’s home because the facility did not supply that type of portable oxygen. Although the resident’s care plan noted oxygen therapy and provision of a portable oxygen apparatus, it lacked interventions addressing the resident’s repeated unsafe storage of portable oxygen cylinders, despite the DON acknowledging the cylinders had been removed from the room several times for safety and that such interventions should have been included on the care plan.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
The facility failed to review and revise care plans at least quarterly and when residents’ conditions or services changed, as required by its care planning policy. Several residents had care plans that had not been updated for over a year despite new hospice admissions, significant weight loss with dietician interventions, and documented unsafe smoking behaviors while on oxygen. Care plans lacked current problems and interventions, such as hospice services, nutrition and weight loss management, and smoking safety, even though recent MDS assessments and progress notes reflected these issues. The DON acknowledged responsibility for overseeing MDS and care planning and confirmed that care plans had not been reviewed or revised as required.
A resident with intact cognitive function had only one documented comprehensive care plan meeting following admission, with no evidence of required quarterly care plan meetings thereafter. The resident did not recall attending any care plan meetings. The MDS Coordinator, responsible for care plan meetings for LTC residents, reported not knowing that quarterly meetings with residents or their representatives were required. The DON stated there was no formal care planning policy and that they relied on CMS guidelines, while a corporate nurse consultant was identified as the MDS Coordinator’s supervisor and trainer for tracking care-plan meetings.
A resident with an identified elopement risk had an elopement care plan initiated but it was never reviewed or revised after multiple subsequent elopement incidents. Record review showed no updates to the original elopement interventions, and staff interviews confirmed that the care plan had not been changed. An LPN believed the DON had recently updated the plan, while the DON stated the plan was not updated because an interim MDS nurse did not perform required duties.
The facility failed to conduct required quarterly care plan meetings with two cognitively intact residents and their representatives, contrary to its own policy and leadership expectations. One resident with multiple sclerosis and dementia had not had a care plan meeting since late the previous year and reported that care plan meetings were not being held. Another resident with a history of stroke and hypertension had not had a care plan meeting for many months, and a family member reported that a recently scheduled meeting was canceled due to lack of available staff, with no subsequent meetings held. The SSD acknowledged that quarterly care plan meetings were not being completed as required, and the DON stated that care plan meetings should occur on admission, quarterly, and as needed.
A resident with dementia and impaired mobility, identified as at risk for falls, experienced multiple witnessed and unwitnessed falls over time, including events causing skin tears, facial laceration, bruising, and swelling. Although some fall-related interventions such as non-slip socks, proper fitting shoes, staff presence, frequent toileting, distraction with snacks, and use of a specialized chair were documented in incident notes or described by staff, these interventions were not incorporated into the resident’s care plan after an earlier post-fall entry. Staff reported relying on the EHR, room postings, charts, or verbal instructions to know interventions, while the DON acknowledged that care plans were supposed to be updated after each fall but that the subsequent interventions were not added and were only reflected in progress notes that CNAs could not access.
Care plan lacked specific vision-related interventions for a resident with severely impaired vision. The resident stated staff had not shown them how to get around the facility or assisted them to and from the dining room, and they relied on other residents for help. The MDS coordinator stated the care plan did not include specifics for how to assist the resident and that there was no process in place for assisting blind residents.
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