Failure to Revise and Implement Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to revise and implement appropriate interventions for two residents, leading to deficiencies in their care plans. Resident #3, who had severe cognitive impairment and hearing loss, experienced multiple falls, including one that resulted in a hematoma on her forehead. Despite her need for frequent supervision and assistance, the care plan did not include interventions for 15-minute checks or adequate supervision. The resident's daughter expressed concerns about the lack of supervision and the resident's tendency to attempt tasks independently, which contributed to her falls. Resident #51, also with severe cognitive impairment, experienced falls from her wheelchair in the TV room. The care plan included the use of a dycem to prevent sliding, but it was not consistently used or documented in the resident's Kardex. Staff members were unaware of the dycem's absence, and the resident's care plan did not reflect the necessary interventions for increased supervision, especially during the evening when the resident's behaviors worsened. The facility's policies on accidents and supervision, as well as comprehensive care plans, were not effectively implemented. The interdisciplinary team failed to update care plans with appropriate interventions after incidents, and communication among staff regarding care plan changes was inadequate. This lack of coordination and oversight contributed to the residents' repeated falls and the facility's failure to meet regulatory requirements for comprehensive care planning.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: New risk evaluations were completed for Resident #51 to reflect accurate information, and their care plans and Kardex's were updated to reflect accurate risk assessments, with appropriate and individualized prevention interventions implemented. Resident #3 is no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. The MDS Coordinator and Unit Managers conducted a facility-wide audit of risk assessments and care plans for residents with a score of 12 or less to identify any discrepancies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Direct Care staff (RNS, LPNs, and C.N.A.S) staff will receive mandatory training regarding review and use of Care Plan/Kardex prior to providing care to Residents. This education will also be completed upon hire and at least annually. All Direct Care staff will be in-service by . Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. Starting on all Licensed nurses (RNs and LPNs) and MDS staff on the proper completion of risk assessments, Individualized care planning, and the importance of ensuring interventions are documented in the Kardex. All Licensed nurses (RNs and LPNs) and MDS staff will be in-service by . Any Licensed nurses (RNs and LPNs) and MDS staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed nurses (RNs and LPNs) and MDS staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or Designee will review a sample of five residents' risk evaluations, care plans and Kardex's weekly for four weeks, then monthly for three months to ensure continued compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) Date of compliance