Failure to Develop and Implement Comprehensive Care Plan for Resident With Suicidal Ideation
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and specific interventions to address a resident’s identified suicidal ideations and significant mental health history. The resident was an older female with bipolar disorder, recurrent major depressive disorder with psychotic symptoms, moderate vascular dementia with psychotic disturbance, anxiety disorder, and epilepsy. Her MDS showed a BIMS score of 14, indicating little to no cognitive impairment, and documented that she felt down, depressed, or hopeless on several days in the prior two weeks. The care plan noted prior behavioral health hospitalizations and that she would exhibit or express depression related to the death of a family member, lack of closure, financial concerns, limited family visits, and feeling confined to her room. Signs and symptoms of depression such as poor appetite and sleep disturbance were documented, and the care plan stated she would speak with the social worker if she needed counseling, identifying the social worker as her mental health professional. The resident’s care plan also documented that she had suicidal ideations, but the interventions listed were limited to listening and providing comfort when she was confused and agitated and communicating in a manner that promoted mental and psychological well-being. Despite multiple serious episodes indicating active suicidal ideation and behavior, the care plan was not revised to include more specific, measurable, and individualized interventions. Progress notes showed that on one occasion a CNA reported the resident had wrapped a draw sheet around her neck, stated she wanted to die and join her husband, and the MD ordered close observation every 15 minutes. On another occasion, the social worker documented that the resident stated she wanted to die, although she denied a plan and said she would not harm herself; the physician was notified and it was noted she had a caregiver with her for two hours daily. Later, the resident directly approached an LVN stating she was feeling suicidal, was looking for a bottle of pills to take, and did not care anymore; she also told police she would use a light bulb in her room to cut herself, leading to her being sent to the hospital. After these events, the care plan for suicidal ideation was not updated with detailed, resident-specific safety measures or clear, measurable objectives and timeframes. The DON stated that each department was responsible for its portion of the care plan, that the MDS coordinator was new and in training, and that there was no clinical manager for approximately two weeks, during which time he was responsible for care plans. The DON believed the existing interventions were appropriate and thought the resident was following them by attending activities and speaking with the social worker, so no additional interventions were added until after surveyor inquiry. The Administrator reported that the resident had been sent to behavioral health facilities multiple times and had previously been found with a bedsheet around her neck after a suicide pact with her husband, and that a 24-hour sitter had been reduced to two hours daily at the resident’s request. The Administrator and Medical Director both believed the resident had long-standing depression and had declined or refused some offered help, and the social worker reported that staff had not informed her of the resident’s continued suicidal ideations and that the resident had refused to speak with her for the last six months. Ultimately, EMS later found the resident unresponsive with an empty and a partially empty bottle of Benadryl at bedside, with multiple seizures en route to the hospital, and she was pronounced dead; family and EMS expressed concern that she may have intentionally overdosed, and surveyors determined that the facility had failed to develop and implement a comprehensive care plan with adequate, measurable interventions for her suicidal ideations.
Removal Plan
- Staff initiated emergency response procedures when Resident #1 was found vomiting and convulsing with an almost empty bottle of Benadryl at bedside.
- Director of Nursing initiated interviews with all staff who cared for Resident #1 to determine whether any signs or changes in mood or suicidal ideations were observed.
- Director of Nursing (or designee) will conduct wellness interviews of all interviewable residents using PHQ-9 questions #1, #2, and #9 to assess for depression symptoms and/or thoughts of self-harm; any concerning responses will trigger immediate interventions including provider notification, psychiatric referral, and care plan updates.
- Social worker (or designee) will visit residents with concerning PHQ-9 responses and reassess ongoing visit needs.
- Social worker/nursing will conduct wellness interviews of non-interviewable residents using PHQ-9 questions #1 and #2 (staff observation); any concerning responses will trigger immediate interventions including provider notification, psychiatric referral, and care plan updates.
- Regional Director of Clinical Operations completed a 100% audit of MDSs, confirming zero residents answered 'yes' to thoughts of being better off dead.
- Regional Director of Clinical Operations completed a 100% audit of MDSs with depressive symptoms.
- Director of Nursing (or designee) will conduct an audit of all current resident care plans to validate measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs identified in the comprehensive assessment; discrepancies will be corrected promptly.
- Director of Health Services Education and Training will train the Staff Development Coordinator (and/or designee) on the policy for comprehensive person-centered care plans with measurable objectives, timeframes, and interventions addressing mental health needs.
- Staff Development Coordinator (and/or designee) will educate all leadership and licensed nurses on the facility policy for comprehensive person-centered care plans with measurable objectives, timeframes, and interventions addressing mental health needs; training will be documented on a Management Training Roster maintained by NHA/HR; retraining will occur annually.
- Employees not trained due to absence, schedule rotation, or other factors will be removed from the schedule until required training is completed and documented.
- Standard operating procedures for handling unauthorized outside medications and required actions if noted in resident rooms will be incorporated into ongoing new-hire orientation for all licensed nurses and nurse managers.
- Identified at-risk residents will be reviewed during clinical meeting to assess for changes in depressive symptoms and/or suicidal ideations.
- Social worker (or designee) will perform wellness interviews using PHQ-9 questions #1, #2, and #9 with a randomized sample of residents; any identified concern will trigger immediate interventions including provider notification, psychiatric referral, care plan updates, and safety measures.
- Social worker will conduct wellness interviews of non-interviewable residents using staff-observation PHQ-9 questions #1 and #2.
- Director of Nursing (or designee) will conduct an audit of all newly admitted residents to confirm PHQ-9 assessments were completed and appropriate care plan interventions were implemented.
- Director of Nursing (or designee) will audit all current resident care plans to validate measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs; discrepancies will be corrected promptly.
- Director (or designee) will conduct an audit of all newly admitted residents to validate care plans include measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs to prevent serious harm or death.
- Audit findings will be reviewed during QAPI meetings; additional audits and education will be determined based on findings.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
Failure to care plan fall risk for a resident with severe vision impairment: A resident identified on MDS/CAA as being at risk for falls had no fall-risk interventions documented in the care plan. The resident required assistance with transfers, dressing, and hygiene, had severely impaired vision, and later sustained an unwitnessed fall from a wheelchair after falling asleep and not locking the brakes, resulting in facial bruising and a skin tear. The MDS nurse stated fall risk was not always added to the care plan if there was no prior fall history, while the DON stated any resident assessed at risk for falls was expected to have care plan guidance for staff.
A facility failed to maintain comprehensive care plans for three residents. One resident had documented activity preferences and needs, but no active activities care plan was in place. Another resident used a BiPAP with staff assistance, yet the care plan did not include the device. A third resident had a suprapubic catheter, but the care plan did not identify the catheter or who was responsible for catheter care and bag changes.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Failure to Care Plan Fall Risk for a Resident With Severe Vision Impairment
Penalty
Summary
The facility failed to develop a care plan for 1 of 13 residents, R15, who was identified as being at risk for falls upon admission. R15’s comprehensive MDS assessment accepted on 12/22/25 identified that the CAA for falls would be addressed on the care plan, with staff to monitor for fall risks related to medication, new surroundings, and adjustment due to vision and hearing deficits. The assessment also directed staff to ensure the call light was within reach, make sure R15 knew where it was located, and attach it so it would not slide away because of her vision impairment. R15’s quarterly MDS assessment accepted on 3/20/26 identified intact cognition, severely impaired vision, and the need for moderate assistance of one staff for transfers, dressing, and hygiene. Interview with R15’s family member identified that R15 recently had a fall after falling asleep while sitting in her wheelchair and falling face forward out of the chair, hitting her face on the nightstand and sustaining facial bruising. The nursing progress note dated 5/1/26 documented an unwitnessed fall in R15’s room after she forgot to lock her wheelchair brakes, fell asleep, leaned too far forward, and tipped out of the chair, resulting in a facial bump and bruise and a skin tear on her right ring finger. Review of R15’s current undated care plan showed no mention that she was at risk for falls and no information describing what staff were to do to minimize her fall risk. The MDS nurse stated that if a resident was identified as being at risk for falls upon admission but had no history of falls, that was not always added to the care plan regardless of the CAA findings. The DON stated it was her expectation that any resident assessed to be at risk for falls would have a care plan section alerting staff to those risks and how to provide care and minimize injury.
Incomplete Care Plans for Activity Needs, BiPAP Use, and Catheter Care
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and maintained for three residents reviewed for care planning. For one resident, a significant change MDS showed severe cognitive impairment and extensive to total assistance for all ADLs, along with preferences for books, newspapers, music, animals, news, groups of people, going outside, and religious services. An activity assessment also documented preferences for individual and group leisure, outings, worship services, nature, prayer, modern music, games, reading, group discussions, news, social activities, and connecting with team members, but the resident’s care plan did not include activity goals, participation, or interventions to address those needs. An activities lead confirmed the resident did not have an active activities care plan, and the administrator stated residents would be expected to have one. For another resident, the quarterly MDS identified intact cognition and use of a BiPAP machine was observed at the bedside with water next to it. The resident stated staff assisted with putting the mask on and off and turning the machine on and off at night. Nursing staff confirmed assistance was provided with the mask, machine, and water chamber, and that the water chamber should be filled weekly with mask and tubing changes documented on the MAR. However, the resident’s care plan addressed ADL deficits related to multiple sclerosis and impaired balance, but did not include any evidence that the resident required or used a BiPAP machine. The RN manager and DON both verified that BiPAP use should have been included on the care plan. For the third resident, the admission MDS identified intact cognition and an indwelling catheter. The resident stated he had a catheter prior to admission and that it had been changed to a suprapubic catheter because of infections, and he verified staff assisted with catheter care. The care plan addressed bladder incontinence with brief use, peri-care, scheduled checks, and monitoring for UTI signs, but did not identify the suprapubic catheter or specify who was responsible for catheter care and changing the catheter bag. The RN manager and DON both stated that catheter information should have been included on the care plan for coordination of care.
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