Failure to Update Care Plan After Resident Falls
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not ensure that the resident's bed was in the lowest position as per the care plan while the resident was in bed. Additionally, the facility did not update the resident's care plan with new interventions after the resident experienced three falls, which placed the resident and other fall-risk residents at risk of serious harm and injury. The resident involved was a male with Fragile X syndrome, muscle weakness, unspecified falls, lack of coordination, and cognitive communication deficit. He had a BIMS score of 0, indicating severe cognitive impairment, and required total assistance for sit-to-stand and bed transfers. Despite being at high risk for falls, as indicated by multiple fall risk evaluations, the facility did not update the resident's care plan with new interventions following his falls, which included injuries such as a hematoma and skin tears. Interviews with facility staff revealed a lack of communication and responsibility regarding updating the resident's care plan. The MDS nurse responsible for the resident's care plan had recently quit, and there was confusion among staff about who should update the care plan. Despite discussions in morning meetings about the resident's falls, the care plan was not updated, and staff were not informed of new interventions. This lack of action and communication contributed to the deficiency identified by surveyors.
Removal Plan
- Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of the findings with no new orders received.
- Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders were received.
- The IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified.
- The Director of Nursing and/ or designee reassessed residents who sustained falls head to toe for pain and injury with no new concerns.
- The Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns for appropriate treatment, care plan interventions and resolutions.
- The Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated.
- The IDT reviewed the falls care plans for residents identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. There were updates completed as indicated.
- The Director of Nursing and/ or designee reviewed the progress notes to ensure resident falls and/ or changes in condition related to falls were identified and addressed. There were no concerns noted.
- The Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions.
- The Director of Nursing and/ or designee reviewed the care plans for current residents who sustained falls for implementation of interventions to address the fall. Where applicable the care plans were modified for individualization.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls.
- The Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy.
- The Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status.
- The Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions.
- The Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift.
- The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk.
- An Ad Hoc QAPI was conducted attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 656- Develop/Implement Comprehensive Care Plan.
- The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months. Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete care plans for oxygen therapy and dentures. Two residents had planned and provided services omitted from their comprehensive care plans. One resident with COPD had O2 therapy documented, but the care plan was delayed and did not include newly received dentures or current oral/dental status. Another resident with pneumonia and CHF had an active O2 order and was receiving oxygen, but oxygen was not included in the care plan.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use: The facility failed to ensure care plans reflected key resident needs and behaviors for three residents. One resident’s plan did not include hospice services despite active hospice care and hospice aide visits. Another resident’s plan did not include use of a sensor pad even though he relied on it to call for help. A third resident’s plan did not reflect that he removed and reapplied his O2 cannula, although he stated he managed his O2 himself and an RN confirmed it.
A resident with multiple fall risk factors and several recent falls had a care plan that listed floor mats, but staff did not have the mats in place until later and could not locate corresponding orders in the EMR. The resident also received multiple high-risk meds, including a benzo, antidepressant, gabapentin, and opioid, yet the care plan did not address medication-related fall risk despite the resident’s falls and the meds’ known side effects.
A resident with PTSD had the diagnosis listed in the face sheet, physician visit, and quarterly MDS, but the care plan did not include PTSD or related interventions. The DON stated she did not see PTSD in the care plan and noted it was important to include the diagnosis so staff could document interventions such as avoiding triggers. Facility policy required person-centered trauma-informed care and individualized interventions, preferences, and triggers to be documented in the care plan.
The facility failed to include EBP instructions in the care plans of residents with a G-tube, a chronic wound, and an indwelling catheter. Observations showed PPE carts and signs directing staff to use gowns and gloves for direct care, but one care plan did not address EBP for G-tube or personal care, another lacked EBP guidance for wound care, and a third lacked EBP guidance for catheter care. The DON stated EBP should be care planned when required and staff were expected to follow the care plan and PPE guidance.
Care plans were inaccurate for multiple residents because current needs were omitted and resolved or discontinued issues remained listed. A resident with a pressure injury had no pressure injury care plan, another resident’s healed venous wound remained on the plan, one resident’s AC therapy and thrush were not updated, a resident on AC medication had no related focus area, and a resident with impaired vision had no vision-related care plan entries.
Incomplete care plans for oxygen therapy and dentures
Penalty
Summary
The facility failed to ensure that all planned and provided services were included in the comprehensive care plans for 2 of 19 sampled residents, Resident 34 and Resident 9. For Resident 34, the electronic health record showed a readmission with diagnoses including COPD, diabetes, and anxiety disorder, and the resident was able to make needs known. The quarterly MDS showed the resident received O2 therapy and had broken or loosely fitting full or partial dentures. During interview, Resident 34 stated they had dentures, but the bottom dentures did not fit right and had been taken a few weeks earlier to be fixed and had not been returned. Records also showed new dentures were received on 04/06/2026, but the focused care plans for ADL self-care performance deficit and oral/dental health problems did not include dentures. The focused care plan for COPD showed the resident was on O2 therapy, but it was not initiated until 06/15/2026, despite the resident having an order for continuous O2 at 2 L/minute via NC starting 05/27/2026. For Resident 9, the electronic health record showed admission with diagnoses of pneumonia, diabetes, and CHF, and the resident was able to make needs known. The record showed a provider order for O2 at 2 liters per minute with a start date of 11/19/2025, and the MDS showed the resident was receiving oxygen during the stay. However, the current plan of care reviewed on 06/17/2026 did not include oxygen. Staff stated the resident should have had a care plan in place for oxygen, and the DNS stated it was the expectation that residents with CHF who received oxygen had it included in their comprehensive care plan, but this did not happen for Resident 9.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that reflected identified resident needs for three residents. The report states that the care plan for Resident #7 did not reflect hospice services, the care plan for Resident #44 did not reflect use of a sensor pad, and the care plan for Resident #81 did not reflect that he took off and put on his oxygen cannula. The facility policy required a comprehensive care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #7 was a female with diagnoses including cerebral infarction and malignant neoplasm of the colon. Her MDS reflected severe cognitive impairment, moderate assistance with ADLs, and hospice care. Her care plan dated 02/17/2026 did not include hospice services, even though active orders reflected admission to hospice for CVA starting 02/04/2026. During observation, she was in bed with a hospice aide applying lotion to her legs, and she stated hospice came and gave her baths and showers. Resident #44 was a male with Parkinsonism, muscle spasms, and seizures. His MDS reflected moderate cognitive impairment, substantial assistance to total dependence for most ADLs, use of a manual wheelchair, and maximal assistance for locomotion and mobility. His care plan dated 05/01/2026 included an ADL self-care deficit and an intervention to encourage use of the call bell, but it did not reflect his sensor pad. During observation, his sensor pad was lying on his bed while he was seated in a tall wheelchair in his room, and he stated he would use the sensor pad to call for help if needed. Resident #81 had acute and chronic respiratory failure with hypoxia and was noted to have moderate cognitive impairment and need for minimal to moderate assistance with ADLs. His care plan addressed oxygen therapy and nebulizer use, but it did not reflect that he removed and reapplied his oxygen cannula. During observation, oxygen equipment was present near his bed, and he stated he used oxygen at night, put it on and took it off himself, and turned the concentrator on and off; an RN confirmed he could remove and replace his nasal cannula.
Incomplete Fall Prevention Care Planning
Penalty
Summary
The facility failed to develop, implement, and revise the comprehensive person-centered care plan for one resident with a history of falls. The resident was admitted with diagnoses including osteoarthritis, spinal stenosis, neurosarcoidosis, obstructive sleep apnea, macular degeneration, and restless leg syndrome. The resident’s care plan, initiated after a fall risk assessment, identified the resident as at risk for falls and fall-related injury due to generalized weakness, limited endurance, impaired balance, unsteady gait, history of falls, and decreased vision, and it included floor mats to the sides of the bed per orders. Record review showed the resident experienced three falls over a little more than one month, including one fall that resulted in shoulder pain and prompted diagnostic imaging. During interview, the resident stated that fall mats were not currently in place but would be liked. The ADON stated fall mats were identified in the care plan but could not locate fall mat orders in the EMR. A CNA stated staff were told by the DON or unit nurse when to place the mats and that staff first started using fall mats on the night of 6/10/26. The Administrator stated the facility was aware of the resident’s increased falls, had discussed the falls with the resident, and had recently ordered additional mats because the facility did not have enough. The resident’s record also showed use of multiple high-risk medications with fall-related side effects, including diazepam, escitalopram, gabapentin, and oxycodone. Review of the care plan showed no interventions addressing medication-related fall risk despite the resident’s falls and the presence of these medications. Facility policies stated that staff, with physician input, would implement a resident-centered fall prevention plan based on specific risk factors and modify care plans when goals and objectives were not achieved.
Missing PTSD Diagnosis and Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #4 that included his PTSD diagnosis and related interventions. Record review showed the resident was admitted and later re-admitted with PTSD, and his physician visit and quarterly MDS also listed PTSD as an active diagnosis. However, the care plan dated 4/22/206 did not include PTSD. During interview on 6/10/2026 at 4:48 PM, the DON stated she did not see PTSD in Resident #4’s care plans and said it was important to include the diagnosis so staff could show interventions such as avoiding certain triggers. The facility’s PTSD Management in Long-Term Care policy stated that residents with PTSD should receive person-centered trauma-informed care and that individualized interventions and resident preferences and triggers should be documented. The facility’s Care Plan policy stated care plans should include identified problems and needs, measurable goals and expected outcomes, and interventions and services to be provided.
Failure to Include EBP in Resident Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included enhanced barrier precautions (EBP) for 3 of 5 residents reviewed who were identified to be on EBP. One resident had intact cognition, required moderate assistance with bathing, had a G-tube, and diagnoses included Parkinson’s disease, narcolepsy, anxiety, and dysphagia. That resident’s care plan addressed incontinence and G-tube care, but did not include instructions for EBP when staff provided G-tube care or personal care. The resident’s active medication orders directed that numerous medications be crushed and administered through the feeding tube, and a sign outside the room directed staff to wear a gown and gloves for direct care, including G-tube care. The DON stated G-tube care was one instance when EBP should be used and that EBP should be care planned when required. A second resident had severe cognitive impairment, obesity, an unstageable pressure ulcer, and moisture associated skin damage. The resident’s wound assessment identified a stable coccyx ulcer, but the care plan lacked any guidance for EBP use. During observation, an isolation cart outside the room had a contact precaution sign for the roommate and did not address whether the resident was on EBP; the cart contained gloves, masks, and eye/face protection, but no gowns. A nursing assistant stated gowns and gloves were not needed for care of that resident and entered the room without wearing either. A third resident had moderate cognition, an indwelling catheter, renal insufficiency, and urinary retention. The care plan included catheter change, daily catheter care, and infection monitoring, but did not include EBP instructions related to the catheter. Observation showed a cart outside the room with gowns and gloves and a sign identifying the resident as on EBP with instructions to wear gowns and gloves for direct care, including catheter care. The DON stated staff were expected to follow resident care plans and the facility policy regarding PPE for EBP.
Care plans missing current needs and unresolved conditions
Penalty
Summary
Care plans were not accurate for 5 of 22 sampled residents because needed care was not included and some resolved or discontinued conditions were not removed. The deficiency involved Residents 7, 5, 27, 4, and 98, and was identified through interview and record review. The report cited WAC 388-97-1020(1)(2)(a)(b). Resident 7 was admitted with stroke and right-sided weakness and had a pressure injury to the bottom. The resident stated their bottom was very sore and was observed lying flat on their back with heels on the mattress. The EHR showed no actual pressure injury care plan, even though a weekly skin assessment documented a stage two pressure ulcer to the bottom. Staff stated the resident should have had a pressure injury care plan but did not. Resident 5 had a focused skin integrity care plan that identified a chronic venous leg ulcer/wound on the right lower leg, but later EHR review showed no documentation of a current venous wound and the MDS showed zero venous ulcers/wounds. Resident 27 had a care plan that still listed anticoagulant therapy and thrush, but the EHR showed no current anticoagulant therapy or thrush infection, and staff stated both conditions should have been updated or resolved in the care plan. Resident 4 received an anticoagulant medication, but the plan of care had no focus area for anticoagulant use. Resident 98 had impaired vision noted on the MDS and stated they could not see well and needed to see the eye doctor, but the care plan had no problem, goal, or intervention related to visual deficit or glasses use.
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