Failure to Develop and Implement Comprehensive Care Plans for Pressure Ulcer and Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, specifically regarding the use of low air loss mattresses (LALM) and fall prevention interventions. For two residents with significant pressure ulcers and related risk factors, the care plans did not specify the required LALM setting levels and modes, despite physician orders indicating the need for these specialized mattresses for wound and skin management. Staff interviews confirmed that the care plans lacked individualized details, and the responsible nurse was unable to clarify the appropriate settings, acknowledging the care plans were not comprehensive or person-centered. Additionally, for a resident with a history of falls and multiple neurological and musculoskeletal diagnoses, the care plan included the use of a floor mat (landing mat) as a fall prevention measure. However, during observation, the floor mat was not in place, and the assigned CNA reported not having seen or placed the mat that day. Documentation did not confirm the mat's use, and the DON confirmed that the intervention should have been implemented and monitored by nursing staff, but there was no evidence this occurred. The facility's own policies and procedures require comprehensive, individualized care plans with measurable objectives and timetables, as well as the implementation of physician-ordered interventions. The deficiencies identified were based on direct record review, staff interviews, and observations, demonstrating a failure to ensure that care plans were both comprehensive and implemented as written for residents with complex care needs.