Failure to Develop and Implement Care Plans for Behavioral and Fall Risks
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with known behavioral and fall risks. One resident, with a history of falling, hypertension, and severe dementia, exhibited a persistent behavior of grabbing onto objects while being transported in a wheelchair. Multiple staff members, including CNAs, LPNs, and the Memory Care Director, observed and were aware of this behavior prior to an incident where the resident grabbed another wheelchair and fell. Despite these observations and the resident's severely impaired mental status, the behavior was not care planned until after the fall occurred. Another resident, also with severe dementia and a history of falls, was identified as being at high risk for falls and had a care plan intervention stating not to leave the resident in bed while awake. However, during the survey, staff were observed leaving the resident alone in bed while awake on multiple occasions, despite the care plan directive. The resident attempted to get out of bed unassisted, and staff acknowledged that the intervention was not being followed at the time. Facility policies and job descriptions reviewed by the surveyor indicated that care plans should be individualized, person-centered, and updated promptly when new behaviors are observed. The failure to timely develop and implement care plans for known behaviors and to follow established interventions for fall prevention directly contributed to the deficiencies identified for both residents.