Failure to Implement Comprehensive Care Plan and Respect Resident Preferences
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan for a resident with multiple diagnoses, including dementia, hemiplegia, and bullous pemphigoid. The care plan for falls, dated 10/16/2023, required staff to keep the resident's personal items within reach and to complete quarterly fall risk assessments as per the facility's fall protocol. However, staff did not ensure personal items were accessible, and a required quarterly fall risk assessment was not completed in March 2025. These omissions were confirmed through record review and staff interviews, with both the MDS Nurse and DON acknowledging the lack of documentation and the importance of these interventions for fall prevention. The resident experienced two unwitnessed falls, one in March and another in April 2025, resulting in injuries such as redness, skin discoloration, and swelling. Observations showed that the resident's personal items, including glasses and water, were placed on a storage container out of reach, prompting the resident to attempt to retrieve them independently, which led to a fall. Staff interviews revealed that the overbed table was left empty because the resident would knock items off, but no alternative intervention was documented or implemented to ensure items remained within safe reach. Additionally, the facility did not develop a care plan to address the resident's or family’s expressed preference for dining location. Although the family requested that the resident eat meals in the dining room, and staff sometimes accommodated this, there was no documented care plan or consistent intervention to support the resident's right to choose meal location. Staff decisions about meal location were made on a day-to-day basis without reference to a care plan, and both the MDS Nurse and DON confirmed the absence of a documented plan addressing this preference.