Care plans were not accurately developed or implemented for several residents with oxygen needs, PTSD, dementia, and epilepsy. One resident received oxygen at a higher flow rate than ordered, another had a new epilepsy diagnosis not added to the care plan, a resident with documented trauma history had no PTSD care plan, and a dementia intervention for a wheelchair cup holder was listed but not in place.
A resident with a history of falls, impaired mobility, incontinence, CVA with R-sided hemiplegia, and arthritis had an order for low-profile bedside mats to be on the floor at all times while in bed. During observation, one mat was against the air unit, one was on the right side of the bed, and the left side had no mat in place; an OTA said he would report it to a nurse and replace the mat.
A resident’s care plan had multiple blank intervention fields for ADL assistance, including bed mobility, eating, toileting, dressing, personal hygiene, and bathing, and the fall-risk goal was incomplete because the number of days was left blank. The care plan also called for turning and repositioning every 2-3 hrs for skin breakdown risk, but task records were missing for several shifts, and the DON confirmed the blank care plan areas and the lack of implementation.
Failure to implement a fall-prevention intervention for a resident with a hx of falls, Parkinson's, and tremor. The care plan and MD order required a fall mat on the left side of the bed when in bed, but staff observed the resident in bed with the call light in reach and no mat in place; the Administrator acknowledged the omission and later reported the mat had been behind the bed.
Incorrect Diagnosis on Care Plan: A resident’s care plan included hemiplegia/hemiparesis despite the diagnosis list and MDS showing no such diagnosis or impairments. The DON confirmed the care plan diagnosis was incorrect.
Care plans were not accurately developed or implemented for a resident's fall interventions, a non-verbal resident's communication needs, and another resident's correct diagnosis. Staff observed missing or incorrectly placed fall-prevention devices, the care plan for the non-verbal resident repeatedly directed verbal communication despite gestures being the resident's method of communication, and a care plan listed lupus instead of the correct diagnosis of lupus anticoagulant syndrome; the DON confirmed these issues.
Person-centered activity care plans were not developed for several residents, as documented preferences such as one-on-one activities, preferred TV shows, music genres, outings, and self-directed activities were missing from the plans. An Activity Director confirmed the plans were not individualized. In another event, a resident’s fall mat was found leaned against the wall instead of placed on both sides of the bed as directed in the care plan, and an LPN confirmed the mat was not in place.
A facility failed to develop and implement activity care plans for two residents. One resident said she mostly stayed in her room and was only asked about bingo, while another said activities seemed pointless and she usually did not attend. Surveyors found no activity care plans in the records, and the Administrator confirmed they were not present.
A resident's catheter care plan was left incomplete, with no type of catheter or reason for use documented, even though the resident required an 18 FR foley for urinary retention and obstruction. Another resident had a BG of 67 mg/dL, but the care plan-required physician notification for BG readings below 70 mg/dL was not documented.
A resident with autism had an activity care plan that was not updated or personalized despite changes in preferences and participation, and staff confirmed the plan was based on a generic library rather than individualized interventions. Another resident had an order for bilateral quarter side rails to support bed mobility, but the comprehensive care plan did not address side rail use, and the DON confirmed it was not care planned.
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