A resident with osteoarthritis, reduced mobility, difficulty walking, a history of falls, and moderate cognitive impairment experienced a fall when they leaned to the side, tipped their wheelchair, and fell to the floor. Staff implemented an immediate intervention by placing a gel cushion in the resident’s wheelchair to help prevent further falls, and the cushion was observed in use. However, the resident’s fall-risk care plan, which addressed falls related to poor safety awareness and cognitive impairment, was never revised to include the gel cushion intervention, despite facility expectations that nurses and supervisors update care plans with new post-fall interventions.
The facility failed to keep a resident’s care plan consistent with the most recent MOLST, resulting in conflicting documentation where the MOLST indicated full code while the care plan and active orders still showed DNR, and the assigned nurse stated she would follow the outdated DNR status. In addition, the facility did not hold required interdisciplinary care plan meetings within the mandated timeframe after MDS assessments for two residents, with no care conference notes documented following those assessments and a social worker operating under an incorrect understanding of the timing requirements and the need for a guardian’s presence.
A resident with spinal stenosis, a lumbar compression fracture, and moderate cognitive impairment was care planned as dependent on two staff and a mechanical lift for transfers, even after PT documented that the resident could perform most of the transfer with only one-person, weight-bearing assistance. The resident’s spouse and a GNA reported that the resident could stand with staff help and no longer required a mechanical lift, but the comprehensive care plan was not revised to reflect these current transfer needs. The MDS coordinator acknowledged the facility was behind on updating care plans and could not explain the lack of revision despite IDT discussions, while leadership stated they expected timely, accurate care plan updates and effective staff communication.
The facility failed to consistently conduct and document care plan meetings and to revise care plans after changes in condition. Several residents reported either not having care plan meetings or not knowing about them, and record reviews showed only single, outdated care plan meeting entries with no subsequent documentation despite multiple MDS assessments that should have prompted quarterly IDT reviews. In addition, a resident who had been discharged from hospice services continued to have an active hospice physician order and an active hospice-related care plan, indicating that the care plan was not revised to reflect the resident’s discontinued hospice status.
Surveyors found that the facility failed to hold and document an interdisciplinary care plan meeting after completion of an MDS assessment for a resident with a urinary catheter. The social worker reported that care conferences are usually scheduled about 2 weeks after MDS assessments and documented in the EHR. Record review showed an MDS completed for the resident, but the only documented care conference was several months earlier, with no subsequent meeting held. The social worker and NHA confirmed that no care plan meeting had occurred since that earlier date, attributing this to the resident’s transition from LTC to skilled care.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
Surveyors found that the facility failed to timely revise care plans after changes in condition for two residents. One resident had new physician orders for PRN and then continuous O2 via nasal cannula, was observed on O2, yet had no care plan addressing oxygen use; the DON acknowledged the care plan should have been updated. Another resident, admitted earlier in the month, sustained a fall from bed, with an RN note indicating fall protocol was initiated; although a fall-risk care plan existed and was revised to add monitoring for medication side effects, it did not capture the actual fall or fully reflect existing risk factors. Only after a second fall was a more detailed fall-risk care plan created, documenting history of falls and multiple contributing conditions that were already present after the first fall, which the DON agreed were not captured in the earlier revision.
Surveyors identified that quarterly care plan meetings were not consistently held for a resident, with documented gaps where required meetings were missed despite the expectation for regular interdisciplinary review. In addition, a resident with documented ongoing inappropriate sexual behavior had a care plan intervention for 1:1 supervision that was not being implemented; the resident was observed without 1:1 supervision, an RN reported the behaviors occurred daily and that 1:1 supervision had not been provided for an extended period, and the DON confirmed the absence of the ordered supervision.
Facility staff failed to hold a required quarterly care plan meeting for a resident after completion of a quarterly MDS assessment. The facility’s process requires the IDT to meet after each MDS to review and revise the care plan, which guides individualized care and is reviewed at least quarterly. Record review showed the last care plan meeting occurred months before the most recent quarterly MDS, with no subsequent meeting documented. Social Services, who keeps care plan documentation, reported that a meeting had been scheduled but then postponed and not rescheduled, resulting in the missed quarterly care plan review.
A resident with severe malnutrition, pharyngeal dysphagia, dementia, and other comorbidities had an existing nutritional risk care plan with goals and interventions related to diet tolerance and monitoring for dysphagia. After an SLP evaluation and a FEES exam, new recommendations were made for a soft and bite-sized/mechanical soft chopped diet with thin liquids and specific compensatory swallowing strategies, including upright positioning, no straws, single sips, small bites, and slow intake, with possible use of a Provale cup. Although these results were available to staff, the RN confirmed that the resident’s nutritional care plan was not updated with any new nursing interventions based on the FEES findings, resulting in a failure to revise the care plan to meet the resident’s needs.
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