Failure to Implement and Develop Required Care Plan Interventions for Falls and PTSD
Penalty
Summary
The facility failed to ensure that care planned interventions were implemented and that comprehensive care plans were developed for residents with specific needs, including fall prevention and management of PTSD. Multiple residents with a history of falls did not have the required interventions in place as outlined in their care plans. For example, one resident with Parkinson's disease and dementia, who had experienced multiple falls, did not have the prescribed call light signage or properly placed non-skid strips in their room, despite these being documented interventions following previous falls. Observations confirmed the absence or incorrect placement of these items during several checks, and staff interviews acknowledged the deficiencies. Another resident with severe cognitive impairment and a history of falls was supposed to have a clip alarm in use as a fall intervention. However, during observation, the alarm was attached to the resident's wheelchair rather than being in use while the resident was in bed, as required. Staff interviews revealed that hospice staff had failed to move the alarm after assisting the resident, and education on this intervention had previously been provided. Similarly, a third resident with severe cognitive impairment and a recent fall was supposed to have non-skid strips in front of their recliner, but repeated observations showed these strips were not present, and staff confirmed the intervention was missing. Additionally, the facility did not develop care plans for residents diagnosed with PTSD, as required. Two residents with PTSD lacked any care plan or interventions addressing this diagnosis, despite facility policy and staff acknowledgment that such care plans should be in place. Other deficiencies included the absence of anti roll back tippers and bright colored tape on a resident's wheelchair, both of which were documented fall prevention interventions. These failures were identified through record review, direct observation, and staff interviews, demonstrating a pattern of not following or implementing care planned interventions for multiple residents.