State Findings:
Based on record review, observation, and interview, the facility failed to ensure care plans were
reviewed/revised to ensure resident’s needs were met for three (#7, 8, and #127) of 13 sampled residents reviewed for care plan revision/updates.
The DON identified the facility census was 30.
Findings:
1. Resident #7 has diagnoses to include severe dementia, benign prostatic hyperplasia with outflow obstruction, and urine retention.
A comprehensive care plan, dated 06/07/21, did not address urine retention or benign prostatic hyperplasia with outflow obstruction.
A physician’s progress note, dated 11/12/21, read in parts, .severe urinary retention .catheterized .with a cystoscope .now has an indwelling Foley catheter .
A physician’ order, dated 11/12/21, documented Intake/output was to be obtained every shift due to the Resident #7 had a Foley catheter.
An admission assessment, dated 11/16/21, documented Resident #7 had an indwelling catheter.
A physician’s order dated 02/02/22, documented Resident #7 had a Foley catheter and intake/output was to be obtained every shift.
A physician’ progress note, dated 03/04/22, read in parts, .Foley catheter in place .
The clinical rccord for Resident #7 did not contain documentation of quarterly assessments to ensure the care plan had been reviewed/revised quarterly. Resident #7 did not have an individualized care plan to ensure interventions were placed to maintain a foley catheter or monitor the medical need for the catheter.
Resident #7’s care plan was initiated on 06/07/21. The care plan was not reviewed/revised to ensure Resident #7’s needs were identified and interventions placed to ensure Foley/catheter care was conducted, obtaining ordered intake/output, and/or monitoring for adverse effects.
On 05/17/22 at 10:24 a.m., Resident #7 was seated in a recliner with a catheter on the floor near the recliner.
On 05/17/22 at 11:30 a.m., the DON, in the presence of the MDS coordinator, was asked to provide copies of assessments and care plans for several residents. The MDS coordinator stated, The assessments and the care plans are not updated.
2. Resident #8 had diagnoses which included, dysphagia, diabetes mellitus, and dementia.
A Physician Diet Order, dated 03/21/22, read in part, .Ground, thickened nectar liquid .
A Dietician Review, dated 03/29/22, read in part, March wt-117.4#. 5% wt loss in 1 month. Notify PCP . Recommend house supplement BID .
A Dietary Communication slip, dated 04/06/22, read in part, .House supplement BID .
A Dietician Review, dated 04/27/22, documented Resident #8 was on a ground diet with nectar thick liquids started on 03/21/22.
Resident #8’s Care Plan, dated 10/12/21 did not have any updates regarding therapeutic diet or any interventions in place for nutrition.
On 05/17/22 at 09:30 a.m., the ADON and Administrator was asked to review the care plan, dated 10/12/21.
They were asked if the care plan addressed the residents’ nutritional needs/diet. They reviewed the care plan and stated the initial care plan did not address nutrition.
3. Resident #127 had diagnoses which included diabetes mellitus, dysphagia, and congestive heart failure.
Resident #127’s comprehensive care plan, reviewed 10/01/21, read in part, I have difficulty swallowing at times and am on a regular diet with ground meat and mechanical soft texture .I want to be well nourished through the next review .The dietary staff will prepare and serve my meals per my physicians orders .
A Physician Note, dated 04/29/22 at 1:00 p.m., read in part, .[Res#127] has dysphagia and signed a dietary waiver in that [Res #127] does not want to eat pureed food however yesterday [Res #127] aspirated and has fever and productive cough .
On 05/11/22 at 2:45 p.m., the ADON was asked if the care plan, dated 05/08/22, was the only care plan Res #127 had. She stated, yes.
On 05/11/22 at 4:30 p.m., the MDS coordinator was asked if there was another care plan prior to his significant change on 05/08/22. The MDS coordinator stated, The one [Res #127] has is the one I created.
On 05/12/22 at 10:10 a.m., the ADON identified Resident #127’s care plan, reviewed 10-1-21.
There was no documentation on the care plan that interventions had been put into place to address the residents nutritional needs and weight loss.
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