Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A resident admitted after hip replacement surgery, cognitively intact and continent of bladder, had a baseline care plan indicating stand-and-pivot transfers. Shortly after admission, the resident reported that a CNA, unable to locate a bedpan and concerned about pain with transfers, suggested the resident could void in an incontinent brief if unable to wait, which upset the resident. Review of the baseline and comprehensive care plans showed they were not revised to include person-centered, comprehensive interventions following this incident. Staff interviews revealed that CNAs depend on care plans for transfer and toileting instructions, that care plans are expected to be available at admission, and that bedpans are typically stored in a main supply closet, while the DON acknowledged that no immediate care plan interventions were added after the event.
Care Plan Not Updated for Current Needs: A resident with diabetes, amputations, contractures, pain, and urinary retention had a care plan that still listed opioids, hand splints, foot care, and urinal assistance even though opioids had been stopped, hand splints were refused, and a Foley catheter was in place. The MDS showed the Foley catheter, but the care plan was not revised to reflect the resident’s current status.
A resident admitted with confusion, a history of falls, and moderately impaired cognition was care planned as a fall risk with limited initial interventions, but the care plan was not updated after multiple subsequent falls, including one with major injury. Although new fall interventions (such as a "Call for Help" sign and changes in mobility equipment placement) were documented in other records and observed in the room, they were not incorporated into the formal care plan. Staff described different fall interventions based on report and observation rather than a unified, updated care plan, and the DON confirmed that nursing staff had not revised the care plan to include the post-fall interventions.
A resident with dementia, severe cognitive impairment, and an activated POA experienced a physical and verbal altercation with another resident and later displayed repeated physical aggression toward staff, including inappropriate grabbing. Despite these documented behaviors and a facility policy requiring care plan review and revision upon status change, the resident’s care plan initially lacked any mention of aggression or sexually inappropriate behavior. When surveyors reviewed the record, the electronic care plan history showed that aggression-related problems and interventions were only added later, while paper copies inaccurately reflected earlier creation dates, demonstrating that the care plan was not updated in a timely or accurate manner after the incidents.
Care plans were not updated to reflect multiple residents’ changing conditions, including new or worsening pressure injuries, a wound, falls, and medication-related needs. A resident with recurrent sacral and ischial pressure injuries, another with a heel wound that declined to stage 3, and others with new skin issues or repeated falls had records showing the events, but the care plans did not consistently include the new problems, refusals, or individualized interventions. One resident’s falls plan was revised late and did not address the cause of the fall, and another resident’s plan did not identify use of a palm guard or antibiotic/antiviral therapy.
A resident with moderate cognitive impairment and a history of wandering left the facility without staff authorization after independently arranging transportation. Although the care plan noted the guardian's permission for the resident to leave for smoking, no new interventions or monitoring were added following the incident, despite facility policy requiring updates to care provision after such events.
The facility did not complete the care plan within 7 days of the comprehensive assessment and did not ensure that a team of health professionals prepared, reviewed, and revised the care plan as required.
A resident with an unstageable pressure ulcer and a history of diabetes repeatedly refused wound care treatments, dressing changes, and compliance with repositioning protocols. Although these refusals were documented in nursing notes, the care plan was not updated to reflect the resident's choices or the facility's response, contrary to facility policy.
A resident with multiple chronic conditions and severe cognitive impairment had a Foley catheter re-inserted for urinary retention, but the care plan was not updated to reflect this change. Despite daily IDT meetings where care plans are reviewed for status changes, the oversight was not corrected, and staff acknowledged the care plan should have been revised.
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