Failure to Update Care Plans After Falls and Wandering Incidents
Penalty
Summary
The facility failed to ensure that care plans were revised and updated for residents following significant events, as required by facility policy. For one resident with chronic obstructive pulmonary disease and depression, multiple falls were documented over several months. Although the facility's Fall Committee investigated each incident and recommended specific interventions—such as moving the resident's room, providing a urinal at bedside, adjusting oxygen tubing, and ensuring non-skid footwear—these interventions were not incorporated into the resident's care plan after each fall. The Director of Nursing confirmed that the care plans should have been updated to reflect these interventions but were not. Another resident with dementia and hypertension experienced several wandering incidents, including one where the resident wandered outside the facility. Progress notes documented multiple episodes of wandering, and the admission assessment indicated a history of wandering. However, the resident's care plan did not include documentation of these incidents or interventions to address wandering. Both the Social Worker and Director of Nursing acknowledged that the care plan had not been updated to reflect these issues.