Failure to Revise and Individualize Care Plans After Falls and Bed Placement
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives, timeframes, and interventions for two residents. Specifically, the care plan for one resident was not reviewed or revised after each incident of falling, despite the resident experiencing multiple falls. Additionally, care plans for both residents did not address the placement of their beds against the wall, which staff identified as a necessary communication tool and a form of restraint that should be care-planned. Interviews with nursing staff and the Director of Nursing confirmed that care plans should be updated after falls and when beds are positioned against the wall, but this was not done. Resident records indicated that one resident had a history of cerebral infarction and major depressive disorder, requiring maximal assistance with transfers, while the other had diagnoses of psychosis and epilepsy and was dependent on staff for dressing, toileting, and bathing. Facility policy required ongoing assessment and revision of care plans when residents' conditions changed, and specifically called for care plans to address the use of restraints. The failure to update and individualize care plans as required was confirmed through record review and staff interviews.