A resident with Alzheimer’s disease, vascular dementia, restlessness, and agitation, and severely impaired cognition had a care plan identifying combative behaviors with an intervention to stop care and reapproach later if the resident became aggressive or resistive. On one shift, during incontinent care, the resident became combative while two NAs attempted to provide care, and a family member assisted by holding the resident to prevent hitting staff so care could be completed. Staff interviews, including with an RN, confirmed that care was continued instead of stopping and reapproaching as directed by the care plan, resulting in a failure to provide care in accordance with the individualized plan.
A resident with dementia, anxiety, and a history of violent behavior had a care plan noting potential physical aggression and general interventions such as reassurance and monitoring, but the plan and care card were not updated with specific, measurable strategies after the resident pushed another cognitively impaired resident, causing a fall and head injury. Despite this initial altercation and temporary one-to-one monitoring, the written interventions remained unchanged, and staff continued to rely on existing generic directions. Later, when the same two residents encountered each other again in one resident’s room, another physical altercation occurred. A NA on duty reported not receiving specific instructions about keeping the two residents apart or how to manage them when in close proximity, while the DON reported relying on verbal staff huddles rather than revising the written care plan and care card.
A resident with dementia, severe cognitive impairment, and a care plan requiring an empathic approach, communication support, assistance with ADLs, and re-approach when care was refused was found lying in another resident’s bed with another cognitively impaired resident. A CNA allegedly entered the room, made profane remarks, and forcefully pulled the resident up by a ponytail despite the resident verbally refusing care and attempting to continue sleeping, rather than leaving and re-approaching later as directed in the care plan. The CNA acknowledged attempting to physically get the resident up immediately and admitted not considering re-approach, while facility policies and CNA job descriptions required respect for residents’ right to refuse care, freedom from abuse, and an empathic dementia care approach.
Surveyors found that the facility failed to update and implement care plans for two residents. One resident with dementia and dysphagia experienced a choking episode and subsequently had provider and therapy orders for a downgraded diet and 1:1 feeding, but the RCP, Kardex, and meal ticket were not revised to reflect the 1:1 feeding requirement, and the resident was later observed self-feeding without indicated 1:1 assistance. Another resident with cognitive and psychiatric diagnoses exhibited ongoing agitation, yelling, paranoia, wandering, and repeated refusals of medications, vital signs, lab work, and care, culminating in an incident involving a roommate, yet no behavior or refusal-of-care RCP had been developed despite this documented pattern.
A resident with dementia, schizoaffective disorder, and adjustment disorder, identified as severely cognitively impaired and living on a secured memory care unit due to behavioral issues, struck another resident, causing facial swelling. After this incident, the resident was moved from a secured to a non-secured unit and continued on 1:1 monitoring, but the existing RCP—developed when the resident was on the secured unit and addressing psychotropic use, refusal of care, paranoia/delusions, hitting, and need for redirection—was not revised to reflect the room change. The DON confirmed the move and lack of RCP updates, and a SW stated the IDT normally meets to adjust the plan of care around room changes, which did not occur, contrary to the facility’s comprehensive care planning policy requiring measurable, data-driven care plans.
Multiple residents with immobility, incontinence, and skin breakdown risk had care plans and NA care cards directing turning and repositioning at least every two hours with skin observation, but staff failed to follow these interventions. A CNA on the day shift reported that at the start of her shift she found several residents with saturated pads, wet briefs, night clothes, and top sheets, suggesting that incontinent care and repositioning were not provided as scheduled on the prior night shift. The DON confirmed that the night CNA reported only two rounds during the shift, video showed the CNA sleeping, and documentation of care was lacking, while the charge RN acknowledged seeing the CNA asleep after first rounds and only up again for second rounds, without notifying a supervisor. These findings show that residents were not consistently repositioned or checked according to their individualized care plans.
A resident with dementia, COPD, dysphagia, severe memory deficits, and dependence on staff for eating had a care plan and Resident Care Card directing a regular pureed diet with thin liquids, aspiration monitoring during meals, and removal of accessible food due to food-seeking behavior. Staff failed to follow these directives when the resident, who habitually wandered at night looking for food, accessed a peanut butter sandwich from a food cart and choked, requiring an LPN to perform the Heimlich maneuver. A NA had previously seen the resident attempt to take and eat food from the cart, did not report these incidents to nursing staff, was unaware of the prescribed pureed diet, and provided snacks at night without knowledge of dietary restrictions, while the DON was unaware of the prior food cart incidents.
Two residents experienced deficiencies in care planning and implementation. One cognitively intact resident with multiple medical conditions and a history of substance abuse had a physician order for an independent LOA, but the care plan was not updated to include goals or interventions related to the LOA, despite facility policy requiring LOAs to align with the care plan. Another resident with diabetes, a left hand contracture, and schizoaffective disorder had documented refusal-of-care behaviors and was to receive nail care on bath days, yet staff reported ongoing difficulty providing nail care due to the contracture and resistance. An LPN was unable to fully assess the nails and did not notify supervisors or the provider, and the DON was unaware of the problem, resulting in no alternative nail care interventions being arranged.
Incomplete Care Planning for Hearing Loss and Dementia: The facility failed to develop comprehensive care plans for two residents with communication and cognitive needs. One resident with metabolic encephalopathy and hearing impairment had later notes showing cognitive deficit, use of a communication device, and a room sign directing staff to use writing supplies, but the care plan lacked documented goals, timetables, and interventions. Another resident with dementia had admission documentation showing severe cognitive impairment and MDS findings indicating care planning was needed, yet staff could not locate a dementia care plan.
A resident with mild cognitive impairment, depression, left foot drop, and moderate protein-calorie malnutrition was admitted with a documented history of left foot drop, yet the facility did not include this condition or related interventions in the resident care plan over an extended period. PT reported multiple attempts to use an AFO brace and re-engage the resident in therapy, all of which were refused, but these refusals and the underlying condition were not care planned by nursing despite communication from therapy. Later podiatry documentation identified thick, yellow, brittle toenails with subungual debris and diagnoses of PVD, neuropathy, onychomycosis, and dermatophytosis, and described aseptic debridement of all toenails with planned follow-up; however, no podiatry-related problems or interventions were added to the care plan. The DON acknowledged that the IDT and licensed nursing staff should have developed comprehensive, individualized care plans for both the left foot drop and podiatry abnormalities in accordance with the facility’s person-centered care plan policy.
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