Failure to revise care plan for trach care: A resident with cerebral palsy, tracheostomy status, and COPD had physician orders for routine trach care, suctioning, saline lavage, trach tie changes, and inner cannula changes, but the comprehensive care plan only addressed impaired respiratory status, oxygen, and securing trach ties. The RN MDS Coordinator and DON confirmed the care plan was not revised to include tracheostomy care.
Care plans were not revised for two residents after new interventions were identified. One resident with severe cognitive impairment and a recent fall had a new Dycem intervention for a recliner, but the fall care plan was not updated. Another resident with dysphagia and a mechanically altered diet had a new MD order allowing thin water only between meals and after oral care, but the care plan was not revised to reflect the order; thin water was observed within reach at the bedside.
A resident with vascular dementia, age-related physical disability, and repeated falls had a comprehensive care plan that did not reflect the bed in lowest position, a floor mat on the right side of the bed, or a nightlight, even though these measures were observed in the room. The DON and Administrator confirmed the care plan had not been revised to include them.
Failure to Revise Care Plans for Skin Changes: The facility did not revise the comprehensive care plans for two residents to reflect changes in skin integrity. One resident had a stage 2 pressure ulcer with physician orders for zinc oxide and heel floating, while the other had scabbed areas, scratches, self-inflicted abrasions, and shearing to the buttocks with related orders for lotion, protective sleeves, and barrier cream. The RN MDS Coordinator confirmed the care plans were not updated to include these skin-related problems and treatments.
Failure to Notify Resident Representative of Care Plan Conferences: A resident with dementia, DM, and anxiety had a care plan initiated and revised, but the record showed only one documented care conference with the RP by phone and no documentation of other invitations or attendee lists. The RP stated she was not invited to care plan conferences, while the SSD said she was responsible for scheduling and inviting the RP and was not keeping a schedule for required care plan meetings.
Care plan not updated and quarterly conference notices missing. A resident with CKD stage 5 on dialysis had a Perma Cath in the right chest, but the comprehensive care plan was not revised to reflect the device or related interventions after a physician note documented the catheter and AV fistula plan. In a separate case, a resident with CHF, dementia, and anemia had no documented quarterly care plan conference notes or invitations for the resident representative after an earlier IDT meeting, and staff could not locate the required documentation.
Failure to document care plan conference participation for two residents. One resident had severe cognitive impairment and the SSD stated the family should have been invited instead of the resident, but the family reported they were not invited to any care plan meetings. Another resident was cognitively intact, was invited to a care conference, but did not attend and there was no completed declination or signature documenting refusal. The MDS Coordinator, SSD, and DON all acknowledged that attendance or refusal should have been documented.
Failure to revise care plan after falls: A resident with a hx of falling, CVA, and muscle weakness had two unwitnessed falls, one involving loss of balance while going to the bathroom and another with the resident found on the bathroom floor with gait imbalance and weakness. Interventions included high-visibility tape on the call light and a 3-in-1 toilet, but the comprehensive care plan did not include these measures even though the resident required assistance with transfers, toileting hygiene, and personal hygiene.
Failure to follow and update orthotic care plans: one resident with a new R distal fibula fracture and order for a tall walking boot was observed in bed without the boot despite the care plan stating it should be worn at all times, and another resident with L arm/hand contractures repeatedly refused a L wrist/hand splint, with refusals documented on the TAR but not in the care plan or nurse's notes.
Failure to update fall care plan after a resident fall. A resident with dementia, osteoporosis, and severe cognitive impairment fell while going to the bathroom unassisted and slipping from a wheelchair onto the right hip. The incident report listed new interventions of non-skid footwear and a bowel training program, but the comprehensive care plan still only identified fall risk related to weakness and was not revised to include the new interventions. The MDS Coordinator and DON both confirmed the care plan had not been updated.
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