DELL RAPIDS, SD - A January 2025 inspection of Dells Nursing and Rehab Center revealed significant failures in maintaining current care plans for vulnerable residents, including those who experienced multiple falls, developed pressure ulcers, and had recurring infections, according to a state survey report.
Multiple Residents With Falls Lacked Updated Care Plans
The inspection found that three residents who experienced repeated falls had care plans that were never updated to reflect new safety interventions or changing needs. The most concerning case involved a resident who fell three times between August and December 2024, including a serious incident on December 28 that required emergency room treatment for a laceration above her left eye.
Despite this pattern of falls and the significant injury, the resident's care plan remained unchanged from August 14, 2024, when it was first identified that she was at risk for falls. The original plan included only basic interventions: a physical therapy evaluation and following the facility's fall protocol.
Another resident with Parkinson's disease and chronic obstructive pulmonary disease experienced seven falls between October and December 2024. During the inspection, surveyors observed this resident in a wheelchair with a full body mechanical lift sling underneath her, indicating she now required two-person assistance for transfers. However, her care plan contained no documentation of fall prevention interventions since her admission in February 2024.
A third resident was observed during the inspection wearing an electronic monitoring device on her wrist that would alarm to alert staff of position changes. Records showed she had fallen ten times between August and December 2024. Despite the electronic monitoring and multiple falls, no fall prevention interventions were documented in her care plan since her admission in May 2024.
The Director of Nursing acknowledged during interviews that care plans should be updated when new interventions are added for residents and confirmed that these residents' plans should have been revised to reflect their changing needs and safety requirements.
Care Plan Deficiencies Extended Beyond Fall Prevention
The failure to maintain current care plans affected residents with various medical conditions. One resident with chronic kidney disease and type 2 diabetes had experienced seven episodes requiring antibiotic treatment for urinary tract infections between August and December 2024. Despite this pattern of recurring infections, her care plan had not been updated since March 27, 2024, when monitoring for infection signs was first initiated.
A nursing assistant interviewed about this resident's care revealed that staff were instructed to watch for behavioral changes that might indicate a urinary tract infection and would collect urine samples when infections were suspected. However, the assistant noted that she did not have access to residents' care plans, highlighting potential communication gaps between care planning and direct care staff.
Pressure Ulcer Treatment Plans Incomplete
A resident who developed a stage II pressure ulcer in November 2024 had equipment and interventions in place that were not reflected in her care plan. During the inspection, surveyors observed that she had two specialized cushions in her wheelchair - a waffle cushion for comfort and a Roho air cushion designed to distribute weight evenly and prevent pressure ulcers. However, the Roho cushion was not properly inflated, and neither cushion was documented in her care plan.
The resident's care plan did reference her pressure ulcer in a nutrition-focused section, noting the need for extra protein to aid wound healing, but failed to document the pressure-reduction equipment that had been provided. When the resident transferred to her recliner, no specialized cushioning was available there despite her history of pressure ulcers.
Medication Monitoring Gaps for Psychiatric Medications
Another significant care plan deficiency involved a resident prescribed both olanzapine for dementia with psychotic disturbance and lorazepam for anxiety. While her care plan included detailed monitoring requirements for the olanzapine, including watching for side effects like unsteady gait and muscle rigidity, it completely omitted any reference to the lorazepam or monitoring for its adverse effects.
The care plan also failed to address non-pharmacological interventions for managing the resident's hallucinations, anxiety, or psychotic symptoms, despite these being standard approaches in dementia care.
Medical Significance of Outdated Care Plans
Current, comprehensive care plans are fundamental to patient safety in nursing home settings. When residents experience falls, develop infections, or acquire pressure ulcers, their risk factors and care needs change substantially. Updated care plans ensure that all staff members understand new interventions, monitoring requirements, and safety precautions necessary to prevent further complications.
For residents with recurrent falls, care plans should evolve to include specific interventions such as increased supervision, environmental modifications, medication reviews, and physical therapy recommendations. Each fall represents an opportunity to reassess and adjust prevention strategies based on contributing factors identified during post-fall analysis.
Urinary tract infections in elderly residents, particularly those with diabetes and kidney disease, require heightened monitoring as they can lead to serious complications including sepsis. Care plans should reflect increased frequency of assessments, specific symptoms to monitor, and prevention strategies such as proper hygiene protocols and hydration management.
Pressure ulcer prevention requires coordinated interventions including specialized equipment, positioning schedules, skin assessments, and nutritional support. When residents develop facility-acquired pressure ulcers, care plans must be immediately updated to prevent progression and ensure proper healing protocols are followed consistently by all staff.
Additional Issues Identified
The inspection also revealed problems with controlled substance accountability and incident reporting. Staff failed to conduct required shift-to-shift counts of liquid morphine sulfate, resulting in six milliliters being unaccounted for on November 24, 2024. The facility did not report this missing controlled medication to the South Dakota Department of Health within required timeframes, with management acknowledging they were unfamiliar with reporting requirements.
An elopement incident involving a resident with vascular dementia was properly managed when it occurred in December 2024, with staff implementing immediate safety measures including electronic monitoring and increased supervision. However, the resident's care plan was never updated to reflect her elopement risk or the interventions put in place.
Facility Response and Corrective Actions
The facility provided corrective education to medication administration staff on December 19, 2024, regarding controlled substance regulations and accountability procedures. Management acknowledged that care plans should have been updated for affected residents and that the Director of Nursing was responsible for implementing these changes following interdisciplinary team meetings.
The facility indicated that interventions were being implemented for residents with safety concerns, but documentation in formal care plans lagged behind actual practice, creating potential for inconsistent care delivery, particularly when temporary or agency staff were involved in resident care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dells Nursing and Rehab Center Inc from 2025-01-16 including all violations, facility responses, and corrective action plans.
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