Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to a resident's care plan, resulting in a fall and subsequent harm. Resident 52, who had a care plan for continence management, was not toileted according to the specified schedule. The care plan required checks and changes upon waking, before bed, before and after meals, and at specific times during the night. However, the resident was last toileted at 9:00 a.m., and the fall occurred later that morning. The resident was found on the floor with a large hematoma on the forehead, complaining of dizziness and an upset stomach, and was subsequently transported to the emergency room for evaluation. The facility's documentation and staff interviews revealed that Resident 52 had been repositioned in a Broda chair multiple times before the fall, indicating attempts to move forward in the chair. Despite these observations, the care plan was not followed, as the resident was not toileted as required. The post-fall investigation confirmed that the root cause of the fall was the failure to follow the toileting care plan, leading to the resident's fall and injury.
Plan Of Correction
In accordance with Facility Policy-Comprehensive Person-Centered Care Plan (#11.01), the Interdisciplinary Team will meet each resident's goals, based on a comprehensive assessment of the resident's physical, psychological, social and spiritual needs. In addition, in accordance with Facility Policy - Minimum Data Set (MDS) Completion (#11.02), residents residing in skilled nursing will be assessed by the Interdisciplinary Team upon admission, annually, quarterly and with significant change in condition. A review of Resident #52 indicated the facility completed assessments for reference periods 5-14-24 to 5-20-24 (Comprehensive Admission Assessment); 8-14-24 to 8-20-24 (Quarterly Assessment) and 11-13-24 to 11-29-24 (Quarterly Assessment). A comprehensive review of Resident #52 Care Plans was completed January 23, 2025 by the Interdisciplinary Team and found to be current. All resident care plans are reviewed annually, quarterly and with significant change in condition. In accordance with the Facility Policy 5.13 - Resident Info SNAP Sheet, the Facility will conduct an audit using the Care Plan Audit Form of all current resident Care Plans, covering Activities of Daily Living, Continence and Falls Prevention Care Plans to ensure Care Plans are current no later than March 7, 2025. Findings will be reported at the next quarterly Quality Assurance Committee meeting. Utilizing a Care Plan Monitoring Tool, beginning February 17th, 2025, a Facility staff member/designee shall monitor 10% of current residents weekly for the first four weeks to ensure care plans of current residents are being followed. Thereafter, monitoring of 10% of current residents will occur on a monthly basis up to 90 days. Findings will be reported at the next quarterly Quality Assurance Committee meeting. All staff will be educated on the definition, importance, and process for the comprehensive plan of care of residents no later than 2/21/2025.