Failure to provide ordered adaptive dining equipment occurred for a resident with hemiplegia and legal blindness. The resident’s care plan and meal ticket specified a plate guard and built up utensils with meals, but an observation found the plate guard missing from the meal tray. The Administrator confirmed the plate guard was ordered and that the care plan was not implemented.
A resident with an indwelling suprapubic catheter for obstructive uropathy and overactive bladder had a care plan intervention to keep the catheter bag and tubing below bladder level and provide a privacy bag. Surveyors observed the urine collection bag without a privacy cover on two occasions, with the bag visible from the room entrance and hallway, and an UM confirmed the care plan instruction had not been followed.
The facility failed to fully develop person-centered care plans for three residents. One resident receiving antipsychotic and antidepressant medications had care plans that did not include the measurable side effects staff needed to monitor, another resident with aphasia had no care plan intervention for a communication board despite staff confirming its use, and a third resident’s documented preference to keep the room door closed was not followed during observation.
A resident’s care plan was not updated to reflect her role as Resident Council President, and another resident’s fall interventions were not followed as written. Staff observed the fall mat on the wrong side of the bed, no "Call don't fall" sign in the room, and an LPN confirmed the ordered setup was not in place; the same LPN also confirmed the resident was not wearing hip protectors.
A resident had physician orders and a care plan requiring fingerstick blood glucose checks and provider notification for readings above 400 mg/dl. Record review showed multiple BG readings over 400 mg/dl, but there was no documentation that the provider was notified, and the DON confirmed the lack of documentation during interview.
A resident with documented PTSD and exposure to disaster, war, and other hostilities was not care planned for PTSD until the care plan focus was added later. Corporate nursing confirmed the resident had not been care planned for PTSD before that point.
Care plans were not fully developed or carried out for three residents. One resident with Bipolar disorder did not have that diagnosis included in the care plan, another resident was supposed to receive showers but was often given bed baths instead, and a third resident had a care plan intervention for a Defined Perimeter Mattress that was not being implemented as documented.
A resident with orders for 1:1 feed assist and supervision at meals was left unsupervised for 8 minutes after tray setup, and staff acknowledged the ordered supervision was not followed. Another resident reported hearing difficulty and use of hearing aids, but the chart and care plan did not address auditory needs; staff were unaware of the hearing issue until the resident could not hear what was being said and a hearing aid was found in only one ear.
A resident’s care plan included general splint/brace interventions such as monitoring effectiveness, providing PROM before application, checking for redness or skin breakdown, and hand hygiene, but it did not specify the exact anatomical placement of the splint/brace. The Administrator confirmed the care plan was not accurate about where the splint/brace should be placed, leaving staff without clear guidance for implementation.
A resident’s comprehensive care plan did not include the resident’s preference or potential for future discharge. Record review found no evidence that the facility assessed whether the resident wanted to return to the community or evaluated discharge potential, and the DON confirmed the item had been missed.
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