Failure to Timely Update Care Plan After Resident Fall with Major Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following a significant change in condition. The resident, an elderly female with diagnoses including dementia, history of falls, impaired mobility, and muscle wasting, experienced a fall resulting in a right arm fracture. Despite this significant event, the care plan was not promptly revised to address the new injury, and the only interventions related to the fracture were added more than two months after the incident. The resident's medical records indicated severe cognitive impairment and a history of falls, with multiple documented incidents of falling, including one that resulted in a major injury. The care plan in place was not updated in a timely manner to reflect the resident's new needs following the fracture. The only care plan interventions related to the arm fracture were initiated over 70 days after the fall, and there was evidence that previous care plan entries may have been deleted or replaced incorrectly, rather than being properly resolved or cancelled. Interviews with facility staff revealed confusion and errors in the care planning process, including the deletion of care plan items and lack of timely updates following significant changes in the resident's condition. The facility's own policy required prompt review and revision of care plans after a status change, but this was not followed, resulting in the resident's care plan not accurately reflecting her current needs after the injury.