Failure to Implement and Revise Individualized Care Plans for Toileting and Safety Needs
Penalty
Summary
The facility failed to fully develop and implement person-centered, comprehensive care plans to address the individualized toileting and safety needs of two residents. For one resident with a history of hemiplegia, hemiparesis, gait abnormalities, and narcolepsy, the care plan included scheduled toileting and fall prevention interventions. However, after multiple falls in the bathroom, including incidents resulting in a laceration and a hematoma, the facility did not complete or document a three-day bowel and bladder assessment as required by the care plan. Additionally, the care plan was not revised in a timely manner to reflect post-fall interventions or assessment results. Another resident with diagnoses including diabetes mellitus and congestive heart failure, and moderate cognitive impairment, experienced a fall with injury while attempting to go to the bathroom. The care plan for this resident included interventions such as a three-day bowel and bladder tracking assessment and a bed alarm to alert staff of unsafe transfers. Despite these planned interventions, the facility did not complete the required bowel and bladder assessment following the fall. Interviews with the Director of Nursing confirmed that the planned fall interventions, including the three-day bowel and bladder assessments, were not implemented for either resident. The clinical records and care plans did not reflect timely or complete documentation of these interventions, resulting in a failure to meet the residents' individualized care needs as required.