A resident’s comprehensive care plan did not include the resident’s Broda chair use or the arrangement for sharing a Broda chair with another resident. The resident had been found unsafe in a personal motorized wheelchair and was recommended for a Broda chair for safety and positioning. The resident said the chair broke and was out for repair for about a week, and the NHA stated the resident and another resident shared a chair during that time without a care plan, schedule, or emergency instructions.
Care plans were not revised for several residents’ sleeping-hour incontinence preferences after an investigation into alleged missed nighttime incontinence care by a CNA. Interviews found some residents reported no concerns, a family representative said the facility addressed the issue immediately, and the DON stated the task of confirming preferences had been delegated to 3rd shift staff but was not yet completed.
The facility did not revise care plans for two residents. One resident started Hospice care and had moderately impaired cognition, but the care plan did not include Hospice-related focus, goals, or interventions. Another resident returned from the hospital with a catheter, but the care plan did not address catheter use. The DON confirmed the missing catheter care plan.
A resident’s comprehensive care plan was not updated after major changes in condition and treatment. The resident no longer had a trach and was eating orally on a fork-mashable texture with thin liquids, but the care plan still listed trach care interventions and tube feeding with a full liquid diet. Observation, interview with the family member, and record review confirmed the outdated plan, and the DON acknowledged the missed updates.
Care plan not revised after resident-to-resident altercation. A resident with dementia, psychotic disturbances, irritability, and anger grabbed another resident’s wrist in the dining room after perceiving a derogatory gesture. Although staff separated the residents and no injury was found, the DON and NHA stated the resident’s care plan was not updated with focus, goals, or interventions to address preventing another resident-to-resident interaction, and agency staff might not know his history or higher risk status.
Care Plan Not Revised After Hospice Revocation: A resident with diagnoses including AKF, DM2, depression, anxiety, and mood affective disorder revoked hospice after previously electing it, but the care plan remained focused on hospice/end-of-life care and was not updated to reflect the resident’s current status, goals, or interventions. The DON stated the hospice care plan should not remain active and expected it to be updated when hospice ended.
Care Plan Not Updated for Refusal of Dentures, Meals, and Tube Feedings: A resident with CVA, dysphagia, aphasia, and moderate cognitive impairment had significant weight loss, but the comprehensive care plan did not address refusal to wear dentures, refusal of pureed meals, refusal to go to the dining room, or refusal of scheduled G-tube feedings. Survey observations and staff interviews confirmed the resident often stayed in bed during meals, disliked the pureed diet, and declined tube feedings because they caused nausea, while the RD documented poor intake and tube feeding refusal as contributing to the weight loss.
A resident with dementia and severe cognitive impairment had a care plan that was not revised to reflect the current level of assistance needed with ADLs, including toileting and brief changes. The POAHC reported staff were not assisting with hygiene after toileting and that the resident had a recent decline and was on hospice, while CNA and DON interviews showed staff relied mainly on repeated offers of care and continued to document the resident as needing only stand-by assistance.
Care Plans Not Updated After Changes in Condition: The facility did not ensure interdisciplinary review and revision of care plans for two residents after changes in status. One resident with severe neuro deficits and dependence for all ADLs had falls and the care plan was not updated with person-centered fall interventions. Another resident with severe cognitive impairment, worsening mobility and bladder incontinence, and an unstageable coccyx pressure injury had care plans that were not revised to reflect increased bed mobility assistance, individualized repositioning, or more specific incontinence interventions.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
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