Failure to Implement Comprehensive Care Plan Leads to Resident's Death
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #1 (R1), who had multiple diagnoses including Alzheimer's Disease, anxiety disorder, and dementia. The care plan specified that R1 should be assisted in a standard wheelchair with a pommel cushion for proper positioning and bilateral elevating leg rests. However, on the day of the incident, Nurse Assistant (NA) #3 did not follow these instructions. NA #3 transferred R1 into the wheelchair without the leg rests and did not ensure the resident was correctly positioned with the pommel cushion. As a result, R1 fell face-first onto the floor while being propelled in the wheelchair, leading to severe injuries including a traumatic subarachnoid hemorrhage, multiple fractures, and ultimately, R1's death. The incident report and interviews with staff revealed that NA #3 had not adhered to the care plan, believing that the resident did not need the leg rests despite the care plan's clear instructions. NA #3 admitted to not checking the care plan and failing to position R1 correctly in the wheelchair. This negligence was corroborated by Licensed Practical Nurse (LPN) #7, who confirmed that the leg rests were not in place at the time of the fall and that R1 was not properly aligned in the wheelchair. Further interviews with the MDS Coordinator, Staff Development Coordinator, and Director of Nursing (DON) confirmed that the comprehensive care plans were intended to guide staff in providing care and were to be followed as written. The failure to implement the care plan as specified led to the tragic fall and subsequent death of R1. The facility's policies and staff training emphasized the importance of adhering to care plans, but these were not followed in this instance, resulting in a severe deficiency in care.
Removal Plan
- Education for staff on the importance of following the Comprehensive Care Plans as written
- Ensuring clinical staff was educated related to finding the Comprehensive Care Plans and implementing them
- Further education for staff on equipment usage, floor training, care plans, and documentation
- Audit and interview with staff to ensure all interventions were in place according to the care plan
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, muscle weakness, and protein-calorie malnutrition had a care plan directing staff to offload his heels or use Prevalon boots while in bed. During observation, he was found in bed without the boots, and an LPN confirmed his heels were not offloaded even though they should have been.
Failure to care plan depression: A resident with MDD and ongoing depressive symptoms had psychology evaluations documenting depressed mood, loss of interest, sleep disturbance, fatigue, and appetite changes, and the MDS listed depression as an active dx. However, the care plan did not include depression as a focus area, and the MDS Coordinator and DON both stated it should have been care planned.
Incomplete care planning for ordered medications and diabetic footwear. The facility did not include ordered meds such as Eszopiclone, Lexapro, Mirtazapine, and Zolpidem in residents' comprehensive care plans, and one resident was not measured for diabetic shoes and insoles per MD order. The MDS Coordinator said the missing medication care plans were an oversight, while the DON and Administrator stated care plans are used to direct and guide resident care.
A facility failed to include person-centered comprehensive care plan focus areas for two residents receiving ordered meds. One resident with atrial fibrillation was receiving Eliquis, and another resident with insomnia was receiving Trazodone, but neither current care plan addressed the medication use. The MDS Nurse stated she was responsible for care plan development and said the omissions were due to oversight.
Failure to update a resident’s fall care plan with a Geri-chair intervention. A resident with dementia, osteoarthritis, diabetes, severe cognitive impairment, and a history of falls had a care plan listing multiple fall precautions, but after a witnessed fall and a physician order for a Geri-chair or tilt back WC, the care plan was not updated to include that intervention. Surveyors observed the resident in a Geri-chair, and the MDS Coordinator and DON acknowledged the care plan had not been updated.
Failure to care plan a resident’s impaired hearing. A resident with dementia and a history of hard of hearing was observed unable to hear normal conversation and stated he refused to use his hearing aid. The SSD and RN confirmed no care plan had been initiated for the hearing impairment or hearing aid refusal, and the DON stated the condition should have been care planned per facility policy and MDS triggers.
Failure to Offload Heels as Directed
Penalty
Summary
Resident #32, who was admitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition, had a care plan revised on 6/18/21 directing staff to offload his heels or use Prevalon boots when he was in bed, as he allowed. During observation on 7/9/26 at 11:22 AM, Resident #32 was found in bed without Prevalon boots in place. At 11:23 AM, an LPN stated the resident should have had his boots on, then lifted the blanket and observed the resident's legs resting on a pillow. When asked whether the resident's heels were offloaded, the LPN stated they were not and confirmed they should have been offloaded.
Failure to Care Plan Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #22, who had diagnoses including Major Depressive Disorder and was documented by psychology evaluations as having recurrent, moderate depression. The resident’s evaluation notes described decreased interest in activities, persistent depressed mood, sleep disturbances, fatigue, and changes in appetite, with symptoms occurring on more than half of the days and causing moderate subjective distress. A later psychology note again documented persistent depressed mood, marked loss of interest, altered sleep patterns, and fatigue with moderate distress. The resident’s quarterly MDS dated 6/13/2026 documented an active diagnosis of depression in Section I, but the care plan did not include a focus area for depression. During interview, the MDS Coordinator stated the resident had been followed by Balance Wellbeing since 12/2025, the diagnosis was entered on 5/20/2026, and depression was not included in the care plan but should be. The DON also stated the resident should be care planned for depression. The facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, and psychosocial needs and all services identified in the comprehensive assessment.
Incomplete Care Planning for Ordered Medications and Diabetic Footwear
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 3 of 4 residents reviewed. Resident #12 had diagnoses including dementia, anxiety, malnutrition, and depression, and her physician orders included Eszopiclone for insomnia, Lexapro for depression, and Mirtazapine for protein-calorie malnutrition. Although these medications were active and administered, the comprehensive care plan dated 04/23/26 did not include care planning for Eszopiclone, Lexapro, or Mirtazapine. Resident #3 had diagnoses including PTSD, depression, and stroke, with a BIMS score of 08 indicating severely impaired cognition. Her physician order dated 06/01/26 included Zolpidem Tartrate 5 mg at bedtime for insomnia, and the MDS indicated she received a hypnotic medication during the look-back period. The comprehensive care plan did not indicate Zolpidem. During interview, the MDS Coordinator stated she reviewed the records and did not see care plans for Resident #12's medications or Resident #3's Zolpidem, and said it was an oversight. Resident #2 was also identified in the deficiency statement as not being measured for diabetic shoes and diabetic insoles per physician order. The facility's policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident and revised as conditions change. The DON and Administrator stated that care plans were a team effort and used to direct and guide resident care, and that if care plans were not done properly, care could be missed.
Missing Care Plan Focus Areas for Anticoagulant and Antidepressant Medication Use
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident receiving anticoagulant medication. Resident #5 was admitted with atrial fibrillation and had a physician order for Eliquis 5 mg by mouth twice daily. The June 2026 MAR showed the resident received Eliquis as ordered, and the quarterly MDS assessment coded the resident as moderately cognitively impaired and receiving anticoagulant medication. However, the resident’s current comprehensive care plan, last reviewed on 6/19/26, did not include a care plan focus area for anticoagulant medication use. The facility also failed to develop a person-centered comprehensive care plan for a resident receiving antidepressant medication. Resident #8 was admitted with insomnia and had a physician order for Trazodone 50 mg by mouth at bedtime. The June 2026 MAR showed the resident received Trazodone as ordered, and the quarterly MDS assessment coded the resident as cognitively intact and receiving antidepressant medication. The resident’s current comprehensive care plan, last reviewed on 6/18/26, did not include a care plan focus area for antidepressant medication use. In both cases, the MDS Nurse stated she was responsible for developing the care plans and identified the missing care plan areas as an oversight.
Failure to Update Fall Care Plan With Geri-Chair Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included all of Resident #1’s fall interventions. Resident #1, a [AGE]-year-old female with dementia, osteoarthritis, and diabetes mellitus, had a quarterly MDS showing a BIMS score of three, indicating severe cognitive impairment, and was assessed as having falls with one fall without injury. Her comprehensive care plan identified her as being at risk for falls related to debility, advanced age, and behaviors, and included interventions such as a low bed with fall mat, tilt back wheelchair, staff education, correct positioning in chair, nonskid tape under the fall mat, use of a call light, monitoring for changes in condition, and a pommel cushion added to the chair. After Resident #1 experienced a witnessed fall from her wheelchair in the TV area, a physician order was entered for safety devices including a low bed, fall mat, and Geri-chair or tilt back wheelchair. At the time of survey observation, Resident #1 was seen in a Geri-chair in the TV area and stated she liked it and was comfortable in it. However, the care plan did not include the Geri-chair intervention. The MDS Coordinator stated she had seen Resident #1 in the Geri-chair but had not yet updated the care plan, and the DON stated whoever had the resident should have seen the order for the Geri-chair and updated the care plan.
Failure to Care Plan Hearing Impairment
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address Resident 33’s impaired hearing. Resident 33 was admitted with diagnoses including dementia, muscle weakness, and abnormal gait and mobility, and the H&P documented a history of hard of hearing. The MDS dated 6/5/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and had minimal difficulty hearing. During an observation and interview on 6/29/2026, Resident 33 was lying in bed and stated he could not hear the surveyor during a normal conversation, that he was hard of hearing, and that he refused to use his hearing aid. The SSD stated the resident had difficulty hearing, refused to use the hearing aid, and had no care plan initiated for impaired hearing. RN 2 later confirmed there was no care plan for the resident’s impaired hearing and that one should be in place to address the hearing impairment and refusal to use the hearing aid so staff could communicate effectively. The DON stated that a resident with impaired hearing should be care planned according to facility policy and that hearing impairment triggered on the MDS should be care planned, including refusal to use the hearing aid.
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