Care plan meetings were not consistently held or documented, and residents were not included in their own care planning. One resident’s care plan was also not revised after she was fitted for an upper denture and was awaiting delivery. The DON and DoSS acknowledged that care plan meetings were behind, and records showed missing quarterly reviews and no documented invitations or attendance for some residents.
Care plan not revised after a perimeter mattress order changed. A resident at risk for falls had a care plan that still included a perimeter mattress even though there was no current provider order for it. The resident was observed in bed without the mattress, and the RD stated the mattress had been used before a hospital transfer, but the intervention was not removed from the care plan when the order was absent.
A resident with C. diff had enteric precaution signage posted at the room entrance, but the care plan did not address the infection or isolation needs until several days after admission. The CEO confirmed the C. diff diagnosis and enteric precautions were not captured in the care plan until that later date.
A resident’s comprehensive care plan was not revised after the discharge plan changed from a short-term skilled stay to LTC. The care plan continued to reflect discharge potential and community referral planning, and the DON confirmed it had not been updated for LTC placement. A later revised care plan stated the resident and RP had chosen LTC due to health and physical needs that could no longer be safely managed in the community.
Care plans were not revised for four residents when their status or needs changed. One resident remained listed as potential discharge despite being LTC, another frequently slept in the dining room and refused redirection to bed, a third repeatedly declined having food cut into small bites and no longer received speech therapy, and a fourth had dialysis access changes that were not reflected in the care plan.
Care plan not updated for a resident’s CIC. A resident was observed scratching the right cheek and had a scratch noted by the surveyor, and the CIC documentation addressed the behavior and short fingernails. However, the care plan had no update for the CIC when reviewed, and a Corporate RN later confirmed it had not initially been updated.
Care plans were not revised after significant changes for four residents. One resident with PTSD and trauma history had no documented trigger assessment or inclusion of psychiatric counseling recommendations in the care plan. Another resident had significant weight loss, but the care plan remained contradictory and no significant change assessment was found. A resident with an unwitnessed fall and head bruise had no new fall-prevention interventions added, and another resident’s care plan was not updated after a diet order changed from thickened to thin liquids.
Surveyors found that the facility did not revise a resident’s oral/dental care plan after all teeth were extracted, leaving the plan to reference natural teeth in poor repair despite the change in condition. In addition, another resident reported never being involved in a care plan meeting since admission, while the MDS coordinator stated the resident declined participation but could not provide documentation of this refusal. These issues demonstrate failures to update care plans after significant changes and to document resident choice regarding participation in care planning.
A resident’s care plan was not revised to reflect his nighttime care preference after an allegation of neglect involving incontinence care at night. Staff later stated the resident did not want to be awakened between 10 PM and 6 AM, but the resident could not clearly confirm that this intervention matched his preference and said he usually sleeps through the night and lets staff know if he needs help.
A resident’s comprehensive care plan was not updated in a timely manner after a change in mental capacity. When the surveyor reviewed the record, the plan still stated the resident had capacity to make her own medical decisions, and it was only updated after the surveyor requested it. The DON acknowledged the update was made after the request.
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