Incomplete care plans and unimplemented fall intervention: A resident with PTSD did not have that diagnosis or related interventions included in the care plan, and another resident receiving furosemide did not have diuretic therapy addressed in the care plan. A third resident had a fall intervention requiring a reaching device, but the device was not in the room or with the resident and was later found at the bottom of the closet; an RN stated it did not appear the resident was using it and was unsure the resident could use it.
A resident’s preference for no male caregivers was documented only in the special instructions section and was not incorporated into the care plan or active physician orders. The SSD stated she had never interviewed the resident about caregiver preferences, and the DON confirmed the directive was not properly reflected to alert all staff.
Care plan documentation for a resident was not person centered and did not include measurable goals. The plan used broad statements about mood disturbance and behaviors, but it did not identify the resident’s specific symptoms, current episode frequency, preferred choices, or the exact signs, symptoms, and side effects staff were to monitor and document.
A resident’s care plan was not developed for the diagnosis of depression or for the use of the antidepressant Cymbalta. During record review, the chart showed no care plan addressing the resident’s depression or psychotropic medication, and the Corporate RN confirmed the omission.
The facility failed to maintain comprehensive, person-centered care plans for three residents. One resident with PTSD had no care plan interventions for the diagnosis or triggers, another resident on comfort-focused care had no related care plan interventions, and a third resident with an order for plastic utensils had no documented care plan interventions or review notes supporting that order.
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.
Care plans were not fully developed or implemented for three residents. One resident’s feelings of abandonment and related anxiety/depression were not addressed in the care plan, another resident’s pressure-reduction wheelchair cushion was not in place despite a care plan requiring it at all times, and a third resident’s discharge plan did not reflect his stated goal to transfer to another SNF closer to family.
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.
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