Failure to Update Behavior and Activity Care Plan: A resident with cognitive impairment and documented physical aggression toward other residents had additional behavior episodes that were not reflected in the care plan. Staff confirmed the resident could not fully comprehend behavior education, there were no resident-to-resident interventions on the plan of care, and activity interventions had not been updated despite the resident not attending groups, needing limited-duration activities, and receiving no one-to-one activities.
Failure to revise a resident’s care plan after multiple nutrition-related order changes. A resident’s diet was changed from a therapeutic diet to a regular diet, weekly wt orders were added due to wt loss, and finger foods were later discontinued, but the care plan was not updated to reflect any of these changes. During survey review, the RDCO acknowledged the missed revisions.
Failure to Revise Care Plan for Resident Behaviors: A resident’s care plan addressed a diet order for Styrofoam and plastic ware, but it did not include a focus, intervention, or behaviors related to the use of plastic ware. The resident was observed eating lunch from a Styrofoam container with plastic utensils in the hallway on two occasions, and an NA stated she was unsure why the resident could not have silverware. The DON and Administrator verified the care plan had not been revised to reflect the resident’s current status and behaviors of throwing dishes and silverware.
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 plans were not kept current for multiple residents, and interdisciplinary care planning was not ensured for one resident. One resident’s care plan still listed an e-cigarette even though the resident said he no longer used one and only used smokeless tobacco, and the DON confirmed the smoking list reflected smokeless tobacco use. Another resident had prior MD orders for a left eye shield after cataract surgery, but was observed without the shield and the care plan had not been revised to match current orders.
Care plans were not reviewed and revised for three residents. One resident had discharge planning and a 30-day discharge notice in the care plan, but there was no evidence a care plan meeting was held and the resident said she had never attended one. Another resident’s chart contained dialysis dry weights despite a care plan directing use of facility weights, and a third resident remained on a tube feeding-related care plan while receiving PEG tube water flushes and a regular diet order.
A facility failed to keep care plans accurate and to involve an incapacitated resident in care planning. One resident’s care plan listed conflicting transfer methods, another resident’s G-tube care plan did not match the physician’s order for pH checks, and a third resident said she had not attended a care plan meeting or been told what was happening while records showed she was incapacitated and the MPOA signed by phone instead of the resident.
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.
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