A resident with dementia, osteoporosis, a right artificial hip, and severe cognitive impairment was care planned as dependent for bed mobility, toileting, and transfers, with an intervention requiring two staff for assistance. Despite this, an SRNA, who knew the resident was a two-person assist, began perineal care alone and rolled the resident onto the side, causing the resident to roll out of bed and fall. An LPN obtained stat x-rays that showed a displaced right femoral shaft fracture, and the resident was sent to the hospital, where surgery was performed and the resident later died on a hospice unit. Staff interviews confirmed that the two-person assist requirement had been in place for years and that the failure to follow the care plan led to the incident.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans and to carry out existing interventions for three residents. One resident with paraplegia and a urostomy managed her own drainage by attaching catheter tubing to her pouch and hanging the tubing over a trash can without performing hand hygiene, and her care plan lacked interventions addressing her self-care and hand hygiene despite her cognitive intactness. Another resident with hemiplegia had a physician order and care plan for a left-hand splint to be worn a set number of hours daily, yet repeated observations showed the splint unused by the TV and no documentation of implementation in the record. A third resident with hemiplegia had orders and a care plan for a right resting hand splint and a left palm guard, but observations over several days showed the right splint not in place and sitting on the bedside table, while staff interviews revealed inconsistent awareness and follow-through on splint orders and care plan directives.
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, and staff did not consistently follow existing care plan interventions. Several residents with PEG tubes, a dialysis catheter, and a colostomy either lacked appropriate EBP care plan focuses at admission or did not have EBP practices implemented as written, including missing door signage and failure to follow tube-feeding protocols. In addition, two residents with PTSD and other mental health diagnoses had active PTSD documented in assessments and psychiatric notes, but their care plans did not address PTSD-related triggers, symptoms, or trauma-informed interventions, despite staff acknowledging these omissions and the importance of accurate, complete care planning.
A resident admitted with PTSD and other diagnoses had a trauma-informed care assessment showing distressing trauma symptoms, but the comprehensive care plan did not address PTSD or include trauma-informed interventions. Staff interviews confirmed the diagnosis was known, yet the care plan lacked the information needed for nursing, CNA, MDS, SSD, DON, and ED staff to identify needs, triggers, and resident-centered interventions.
A resident with pneumonia, atrial fibrillation, coronary artery disease, and hypertension was admitted with an IV antibiotic infusion and ordered weekly weights. The care plan required staff to monitor for cardiac dysfunction, including edema, and to notify the physician of significant weight changes, consistent with facility policy. Over approximately two weeks, the resident gained more than 17 pounds and developed progressive edema observed by family, but there was no documentation that nurses notified the physician or consistently assessed for edema. Staff interviews confirmed lack of physician notification and incomplete assessment practices, and the APRN reported not being informed of the weight gain until the day of hospital transfer, where the resident was admitted with fluid overload and MI and later expired. Surveyors cited the facility for failing to develop and implement a comprehensive, resident-centered care plan, including resident-specific interventions for continuous IV fluids and timely response to significant weight changes.
A resident with multiple chronic conditions had a documented Full Code status and an advance directive care plan requiring CPR to honor the resident’s wishes. When the resident was found unresponsive, not breathing, and cold to the touch, a KMA and an RN assessed the resident but did not initiate CPR, and no documentation showed that life-saving measures were attempted. Staff interviews revealed that the RN was unaware of the resident’s code status, the KMA did not verify it or initiate emergency procedures, and both relied on the KMA’s outside role as a deputy coroner rather than following the care plan, resulting in the resident’s death without implementation of the ordered Full Code interventions.
A resident on Hospice with CKD and HF did not have the CCP updated to include Hospice-oriented goals or interventions for comfort-focused care. The MDS Coordinator stated Hospice status should be reflected in the care plan, and the DON, Administrator, and Medical Director all stated care plans were expected to guide staff in meeting resident needs.
A resident with dementia, scoliosis, and impaired mobility had a comprehensive care plan and assignment sheet specifying use of a total mechanical lift with a green sling and two-person assist for all transfers. Despite this, a CNA independently transferred the resident from a wheelchair to a bed without using the lift or a second staff member, causing a full-thickness laceration to the resident’s lower leg from contact with the bed frame that required hospital treatment and suturing. Interviews and record review showed the lift requirement and sling color were clearly documented and accessible to staff, and nursing leadership stated the CNA was aware of these care plan interventions but did not follow them.
A resident with dementia, severe cognitive impairment, and anxiety was care planned to live on a secured memory unit with supervision and structured diversion activities due to elopement risk. In the days before the incident, the resident repeatedly voiced a desire to go home. On the night of the event, an exit alarm sounded, but CNAs and an LPN were occupied providing showers and other care, and although one CNA briefly redirected the resident from the exit door, staff did not ensure ongoing supervision or verify the resident’s whereabouts after silencing the alarm. The resident left the unit and facility without staff knowledge and was later found in a nearby park by community members and law enforcement, while facility staff initially believed the resident was still in her room. Staff interviews confirmed that required supervision and person-centered diversion interventions from the care plan were not implemented at the time.
A resident with a history of swallowing disorders and a physician-ordered pureed diet was provided a peanut butter sandwich by a CNA, despite clear SLP recommendations and staff awareness of dietary restrictions. The care plan lacked specific interventions to ensure snacks met the resident's prescribed diet, leading to the resident choking and subsequently dying. Staff interviews confirmed the absence of individualized care planning and unclear guidance on acceptable foods for modified diets.
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