Failure to Update Care Plan for Resident's Toileting Needs
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised to meet the resident's current needs. Specifically, the care plan for a resident who required assistance with toileting was not updated to include interventions for monitoring the resident's noncompliance with toileting assistance. The resident, who had moderately impaired cognition and an ostomy, was observed toileting themselves without staff assistance, contrary to the care plan that indicated they required staff assistance for toileting transfer and hygiene. The resident's care plan, developed in 2023, documented that the resident was resistive to Activities of Daily Living assistance, but it did not include specific interventions to address the resident's noncompliance with toileting. Despite ongoing education and encouragement from staff, the resident continued to be adamant about their choices and often did not ask for help. The facility's policy required the care plan to be revised quarterly, annually, and as needed, but no new interventions had been developed since April 2023. Interviews with staff revealed that they were aware of the resident's attempts to be independent and did not call for help, yet the care plan was not updated to reflect this behavior. The Director of Nursing Services acknowledged that the care plan should have been evaluated for effectiveness and revised to include additional interventions to ensure the resident's safety during toileting. The lack of updated interventions in the care plan led to the resident not receiving the necessary assistance, as documented in the Certified Nursing Assistant Accountability records.
Plan Of Correction
Plan of Correction: Approved January 28, 2025 Plan of Correction FTAG 657 SS:D I. Immediate Action a. Resident #21 is still residing in the facility. Resident #21 was affected by this deficient practice. All residents requiring staff assistance with activities of daily living including toileting transfer and toileting hygiene and are non-compliant with activities of daily living have the potential to be affected by this practice. No other residents were affected. b. Certified Nurse’s Aide #1 was educated on 1/16/25 by the Assistant Director of Nursing on following all the instructions for providing care to the residents as documented on the Nursing Assistant Accountability Records with emphasis on reporting all non-compliance observed by the resident to the Nurse and rendering the level of assistance as instructed on the residents Accountability Records. Emphasis also reinforcing that a resident noncompliance does not remove the responsibility from the staff member to render the level of assistance documented on the Accountability record to provide the resident care. c. The resident’s noncompliance care plan was reviewed by the ADNS on 1/15/25 and updated with interventions including staff member offering toileting q 2 hours and prn and must always remain with the resident during toileting hygiene and toileting transfer task to maintain the safety of the resident at all times and to ensure any non-compliance with care is addressed. d. The Residents Activity of Daily Living Care plan was reviewed by the ADNS on 1/15/25 and updated with interventions including offering toileting q2 and prn. Staff member must remain with the resident at all times for all ADL care requiring staff assistance to monitor and provide assistance and maintain the resident’s safety at all times. Also updated to include minimal assistance of one person for toileting hygiene and moderate assist of one person for toilet transfer. e. The Nursing Aide Accountability record was reviewed by the ADNS on 1/15/25 and updated to include staff member must render the level of assistance as documented on the residents’ instructions. Also updated to include offer resident toileting q2 hrs. and prn, minimal assistance of one person for toileting hygiene and moderate assistance of one person for toilet transfer and to report all residents refusal of care and noncompliance to the nurse. f. RN #1 was provided with 1:1 education by the ADNS on 1/16/2025 on updating the Accountability record for the resident care to include intervention for monitoring residents with noncompliance. Ensuring noncompliance behavior has an intervention including interventions for offering toileting to the resident q2 and prn and for staff members to remain with the resident during all tasks requiring assistance and to ensure residents safety is maintained and also to follow up and reevaluate the effectiveness of these interventions with the IDT Team to ensure compliance. g. All LPNs who worked on unit (NAME) on 12/26/24 were provided with 1:1 education by the ADNS on 1/17/25 on following all instructions for care for the residents and reinforcing and ensuring the Aides are following the resident’s plan of care. If a resident demonstrates non-compliance the RN should be notified and the necessary follow up be done with the MD and the IDT team. The resident’s non-compliance does not remove the staff responsibility for rendering the level of care documented on the care instructions. II. Identification of Others a. An audit was conducted on 1/15/25 by the ADNS for all residents in house with noncompliance care plans related to ADL care including toileting self and requiring staff assistance. There were no negative findings of this audit. III. System Changes a. The Facility’s Policy and Procedure Titled Comprehensive Care Plan and Resident Meeting dated (MONTH) 2024 was reviewed on 1/16/25 by the Medical Director, Director of Nursing, and the Administrator with no changes made. b. All Licensed Nurses will be re-educated by the Inservice Coordinator/designee on the Policy and Procedure Titled Comprehensive Care Plan and Resident/Patient Meeting with emphasis on reviewing and revising the comprehensive care plan with interventions to meet the resident’s current needs. IV. Quality Assurance a. An audit tool was created by the Director of Nursing to review all residents with new episodes of non-compliance with Activities of Daily Living to ensure there are appropriate interventions to address the resident’s non-compliance and ensure the Aides accountability record and the residents noncompliance care plan is updated with these instructions and interventions. b. Audits will be completed by the ADNS/Designee on 25% of all residents on each unit weekly x 4, then monthly x 2 months and quarterly thereafter until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Director of Nursing immediately. All negative findings will be immediately addressed by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4 (to review and discuss any unfavorable patterns that may prevent achieving 100% compliance). V. Person Responsible Director of Nursing
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Update Care Plans for Comfort Care and Pressure Ulcers: The facility did not revise the care plan for a resident placed on comfort care after a clinic visit showed worsening fluid retention, cough, swelling, and decreased strength; the plan omitted the no-hospitalization order, discontinuation of labs, and guidance for comfort if the resident declined. The facility also failed to update another resident’s care plan after the MDS identified four Stage II pressure ulcers, leaving only general skin-risk interventions instead of wound-specific goals and treatment measures.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Care plans and related care guides were not updated for a resident with pain, a resident with recurrent falls, and a resident with severe cognitive impairment and transfer needs. One resident’s plan lacked individualized nonpharmacological pain interventions, another resident’s plan omitted a motion sensor that staff were using for fall prevention, and a third resident’s plan and Kardex incorrectly stated the resident was independent with transfers despite staff using a transfer belt and Hoyer lift with two-person assistance.
Failure to revise care plans for two residents left key safety and behavior needs undocumented. One resident with dementia had scissors removed after cutting clothing and hair, but the care plan did not include supervised scissor use. Another resident with a wander guard repeatedly wanted to go outside and attempted to go out on his own, but the care plan did not identify elopement risk or specific interventions for staff. Interviews confirmed staff knew about both residents’ needs, yet the care plans did not reflect those changes.
Failure to update care plan after change in condition: A resident was hospitalized with acute urinary retention and constipation related to neurogenic bowel, but the care plan was not revised to reflect the new diagnosis or related interventions. The MDS Director and MDS Coordinator stated they were unaware of the hospital transfer and acknowledged the care plan should have been updated to support coordinated, individualized care.
A resident with a history of anemia, moderate dementia, and chronic pain had active orders for aspirin for CAD and sertraline (Zoloft) for depression and chronic pain, but the comprehensive care plan was not revised to reflect current diagnoses and medication indications. The care plan continued to reference anemia and daily aspirin for antiplatelet therapy and included a directive to administer antidepressants for chronic pain without specifying sertraline’s use for both depression and chronic pain. An MDS nurse acknowledged that the resident no longer had an active anemia diagnosis and that the care plan should have been updated to clarify the current clinical rationale for aspirin therapy and the indication for sertraline.
Failure to Update Care Plans for Comfort Care and Pressure Ulcers
Penalty
Summary
The facility failed to revise the care plan for a resident who was changed to comfort care only after a clinic visit identified worsening fluid retention, weight gain, generalized swelling, decreased strength, occasional shortness of breath, and a persistent cough. The physician ordered that the resident not be hospitalized, that metolazone be stopped, Lasix be increased to 80 mg twice daily, and that labs be discontinued per family request. The current care plan addressed diuretic therapy and a goal for the resident to be free of discomfort, but it did not include the comfort care status, the order not to hospitalize, the discontinuation of lab draws, or instructions for maintaining comfort if the resident’s condition worsened. Nursing notes showed the resident remained in her room in a recliner and was heard coughing continuously, with the cough worsening. Staff administered PRN morphine for chronic cough related to fluid overload, but it was ineffective and the resident reported severe pain and no relief from the cough and discomfort. Additional notes documented continued coughing, shortness of breath, and little relief after cough syrup and morphine were given. The DON acknowledged the care plan should have been revised to identify what staff were to do to provide comfort if the resident’s condition worsened. The facility also failed to revise the care plan for another resident who developed pressure ulcers. The resident’s comprehensive MDS identified four Stage II pressure ulcers, and the CAA directed staff to address the wounds on the care plan with daily treatment, weekly and as-needed monitoring, physician notification for decline or signs of infection, and goals to slow or minimize decline and provide symptom relief or palliative measures. However, the current care plan only identified the resident as at risk for skin integrity impairment and included general measures such as nutrition, moisture control, skin care, and barrier cream use; it did not identify the actual pressure ulcers or include interventions to promote healing or reduce infection or discomfort. The MDS nurse stated she missed revising the care plan to include the pressure ulcers, and the DON stated it was her expectation that a pressure ulcer be identified on the care plan with appropriate goals and interventions.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Care plans not updated for pain interventions, fall precautions, and transfer needs
Penalty
Summary
The facility failed to update care plans and related care guides to reflect current, individualized interventions for three residents. For one resident with quadriplegia related to a spinal injury and ongoing pain, the admission MDS showed intact cognition, scheduled pain medication, and no non-medication pain interventions. The resident stated he had a lot of pain and had been seen by a pain doctor, but the care plan only listed general pain management and comfort measures without identifying the resident’s preferences for nonpharmacological interventions or documenting whether any had been attempted, effective, ineffective, or preferred. The MAR/TAR and progress notes also lacked identification of nonpharmacological pain interventions. For another resident with moderately impaired cognition and a history of multiple falls, the quarterly MDS documented two or more falls with no injury and one fall with nonmajor injury. The care plan included several fall precautions such as frequent safety checks, a low bed, a floor mat, and non-slip footwear, but it did not include the motion sensor with automated auditory reminders that staff were using. Staff observed the resident with the motion sensor in place, and nursing staff stated the device had been used since after a fall in November 2025. The care plan did not identify when the motion sensor should be used or what adverse effects should be monitored. For a third resident with severe cognitive impairment, delusions, behavioral symptoms, and diagnoses including dementia with behavioral disturbances, anxiety, affective disorder, diabetes, and hearing loss, the care plan and Kardex stated the resident was independent with transfers. However, staff observed the resident being transferred with a transfer belt, requiring assistance from two nursing assistants, and later being moved to and from twin mattresses placed on the floor using a Hoyer lift with two staff. Staff confirmed the resident was not independent with transfers and that the care plan and Kardex had not been revised to reflect the resident’s current transfer ability or the use of the Hoyer lift and mattresses on the floor.
Failure to Revise Care Plans for Safety and Elopement Needs
Penalty
Summary
The facility failed to revise the care plan for 2 of 12 sampled residents, R15 and R18, after changes in condition and identified needs were documented. The report states the care plan was not updated within 7 days of the comprehensive assessment and was not prepared, reviewed, and revised by a team of health professionals as required. Review of the records and interviews showed that the existing care plans did not reflect the residents’ current assessed needs and behaviors. For R15, the 4/6/26 quarterly MDS showed severely impaired cognition, with independence in dressing, toileting, and ambulation using a walker, and diagnoses including Alzheimer’s disease, dementia, muscle weakness, hallucinations, anxiety disorder, and long-term pain medication use. On 5/4/26, R15 stated the facility had taken away her scissors and she could no longer use them for knitting, while a bag of yarn and string was observed near her recliner. A 4/15/26 progress note documented housekeeping staff reported R15 had been cutting her clothes and had cut her hair, and social services noted a plan for supervised scissor use. R15’s care plan addressed leisure preferences and one-to-one interactions, but it did not include supervised assistance with scissors for safety reasons. The IDON confirmed R15 had been cutting her clothing and hair, was not safe to use scissors unsupervised, and that the care plan should reflect that need. For R18, the 5/6/26 quarterly MDS showed a BIMS score of 13, indicating cognition intact, with independence in dressing, toileting, and ambulation using a walker, wandering noted during the assessment period, and use of oxygen and multiple medications including antipsychotic, antidepressant, hypnotic, anticonvulsant, pain, and antiplatelet drugs. On 5/4/26, R18 stated he had an alarm on, wanted to go outside, and believed it was illegal that he could not go out by himself; he also said staff told him he needed someone to go outside with him but there was never anyone available. His care plan noted cognition-related needs and a wander guard, but it did not identify elopement risk, a goal, or interventions for what staff should do if he attempted to leave or when he wanted to go outside. The elopement evaluation left the risk for wandering and/or elopement blank, and interviews confirmed staff knew he wanted to go outside, sometimes attempted to go out on his own, and that the care plan lacked detailed interventions.
Failure to Update Care Plan After Hospitalization
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #38 to reflect a significant change in condition after the resident was diagnosed in the hospital with acute urinary retention and constipation related to neurogenic bowel. A review of the resident’s hospital record showed this diagnosis on 04/21/2026 at 12:05 AM, but none of the resident’s care plans reflected the new condition or related needs. During an interview on 04/27/2026, Resident #38 stated that episodes of constipation had previously led to urinary retention requiring self-catheterization. On 04/30/2026, the MDS Director and MDS Coordinator stated that care plans were revised after hospitalizations and with changes in condition, but they were not aware the resident had been transferred to the hospital. They acknowledged that the care plan should have been updated to include the resident’s new diagnosis and appropriate interventions and monitoring, and the facility policy stated that care plans are revised as residents’ information and condition change.
Failure to Update Care Plan With Current Diagnoses and Medication Indications
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was revised to reflect accurate and current information for one resident. The resident was admitted with multiple diagnoses including anemia, moderate dementia, and chronic pain, and had physician orders for aspirin 81 mg daily for CAD and sertraline (Zoloft) 50 mg daily for depression and chronic pain. The comprehensive care plan continued to list a problem statement indicating a history of anemia with a requirement for daily aspirin for antiplatelet therapy, initiated several years earlier, and included a directive for licensed nursing staff to administer antidepressants for chronic pain. However, the care plan was not updated to specify that sertraline was being administered for both depression and chronic pain, and it was not revised to reflect that the resident no longer had an active diagnosis of anemia or to clarify the current clinical rationale for aspirin therapy. During an interview, the MDS nurse acknowledged that the care plan should have been revised to accurately reflect the resident’s current diagnoses and medication indications. This failure created the potential for inaccurate care planning and inconsistent implementation of care, as the written care plan did not align with the resident’s current clinical status and medication orders as identified through record review and staff interview.
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