Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to revise the individual comprehensive care plans (ICCP) for two residents following falls, which is a deficiency in care planning. Resident #55, who was hospitalized and later readmitted, had a history of a right hip fracture and was completely dependent on staff for mobility. Despite being identified as a high risk for falls after a fall incident, the resident's care plan, which was last revised months prior, was not updated with new interventions until after the surveyor's inquiry. Resident #14, who had multiple diagnoses including chronic obstructive pulmonary disease and congestive heart failure, experienced several falls over a few months. The resident's care plan, which identified them as at risk for falls due to impaired mobility and other factors, did not include new interventions after falls on specific dates. The Director of Nursing acknowledged that the care plan should have been updated with new interventions following these incidents. The facility's policies on fall prevention and care plan revisions require that care plans be updated with new interventions following a fall. However, the care plans for both residents were not revised in accordance with these policies, leading to the identified deficiency. The Director of Nursing confirmed that the care plans should have been updated with new interventions as changes occurred.
Plan Of Correction
1. Residents affected by the deficient practice: Resident #55's care plan was updated with interventions upon readmission on 12/6/24. Resident #14 had no NJ Exec Order 26.4b1 requiring further care plan intervention. 2. Identifying other residents who could be affected by the deficient practice: All Residents who have a fall or who have an incident could be affected by this deficient practice. Current residents with a fall were audited for care plan updates with no noted issues. 3. Measures or systemic changes to ensure that the deficiencies will not recur: U.S. FOIA (b) (6) Unit Managers, Nursing Supervisors and Licensed Nurses in-serviced on the Policy for Incidents/Accidents and the process by Director of Nursing. Emphasis placed on the timing of completing the care plan with a new intervention at the time of the incident. 4. Monitoring the continued effectiveness of the systemic change: The Director of Nursing/Designee will audit five resident incident reports to ensure timely completion of CarePlan interventions weekly x 4 then monthly x 3. Results of audit will be reviewed at Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.