Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure accurate and updated care plans for two residents, leading to deficiencies in their care. Resident #2, who had multiple diagnoses including senile degeneration of the brain and heart failure, was found with bruising and a right clavicle fracture after a fall that was not reported by a staff member. Despite the fall occurring on 01/15/25, no interventions were added to her care plan until 02/10/25, and the care plan was not updated to reflect necessary fall interventions. The Director of Nursing confirmed that the care plan should have been updated to guide staff in the resident's care. Similarly, Resident #3, with diagnoses including hereditary ataxia and Parkinson's disease, experienced falls on 01/08/25 and 01/16/25. However, no interventions were added to the care plan following these incidents until 02/13/25. The Director of Nursing acknowledged that interventions were supposed to be implemented after each fall but were not documented in the care plan until much later. This lack of timely updates to the care plans resulted in a failure to provide adequate guidance to staff for preventing further falls and injuries.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. On Residents #2 and #3 had a resident centered comprehensive care plan updated to reflect changes identified related to interventions. 2. A quality review of current residents comprehensive care plans was completed by MDS Director/designee to ensure comprehensive care plans are developed and implemented regarding interventions. Issues or concerns were addressed as they were identified. 3. All Interdisciplinary care plan team members responsible for writing care plans re-educated on the facility's policy and procedure for developing Comprehensive Care plans: Development and Implementation of a new intervention for each and review of interventions for appropriacy. Direct care staff re-educated on Kardex review for interventions and reporting non-compliance and/or ineffectiveness of interventions. 4. DON/Designee will review new admission records for initiation of Baseline Care Plan five times a week X 3 months. DON/Designee will review resident records for documentation to include, Change in Condition, MD Notification, Responsible Party Notification, Care Plan Update with intervention and placement on Kardex five times a week X 6 weeks; three times a week X 4 weeks, twice a week X 2 weeks, then weekly and PRN as indicated. MDS Coordinator will review care plans weekly in accordance with care plan review schedule. All care plans will be updated as indicated X 3 months. Audit results will be reviewed by the QAPI Committee until such time consistent substantial compliance has been achieved.