Failure to Implement Care Plan Leads to Resident Falls
Penalty
Summary
The facility failed to implement care plan interventions for a resident, leading to multiple incidents of falls and injuries. The resident, who was admitted with severe cognitive impairment and was dependent on staff for toileting, was observed being assisted by only one CNA, contrary to the care plan that required two staff members for toileting assistance. The CNA, who was an agency staff member, was not familiar with the facility's Kardex system and was not aware of the resident's specific needs for assistance. The resident experienced several falls, some resulting in minor injuries, due to inadequate supervision and assistance. The care plan was updated multiple times following these incidents, but the interventions were not consistently implemented. For instance, the use of floor mats requested by the resident's family was not documented in the care plan, and a planned training program for staff was not carried out. The resident's daughter expressed concern over the facility's inability to prevent further falls and injuries. Interviews with facility staff revealed a lack of training and communication regarding the resident's care needs. The MDS Coordinator confirmed that the care plan interventions, such as the use of two staff for toileting and the implementation of a training program, were not properly executed. The facility's failure to adhere to the care plan and ensure staff were adequately informed and trained contributed to the resident's repeated falls and injuries.
Plan Of Correction
1. Resident #120's care plan updated with two-person assist, mats, and implemented programming. 2. All high-risk residents' care plans reviewed, referrals made, and care plans updated as necessary initiated completed. 3. Staff re-educated on use of Kardex, interventions, and toileting support initiated with projected completion. 4. Daily review in clinical meeting, weekly audit at risk meeting ongoing and reported to QA committee monthly. Reviewed in QAPI. 5. Report to QA committee will continue monthly for recommendations and or revisions. Completion Date: