Failure to Revise Care Plan for Resident with Repeated Falls and Bathroom-Related Behaviors
Penalty
Summary
The facility failed to review and revise the care plan for one resident with advanced Alzheimer's disease who had a history of falls and repeated attempts to ambulate independently, particularly when needing to use the bathroom. Despite multiple documented incidents and behavior notes over several weeks indicating the resident's tendency to walk without assistance or his walker, especially to the bathroom, the care plan did not address these specific behaviors. The care plan focused on general fall risk interventions but did not include strategies tailored to the resident's bathroom habits or his repeated attempts to ambulate unassisted. The resident's medical record showed a pattern of falls and near-falls, often related to attempts to use the bathroom independently. Observations and notes from staff consistently documented these incidents, yet the care plan was not updated to reflect the resident's specific needs or to address his bathroom-related behaviors. The deficiency was identified during a review of the resident's care plans, which lacked any mention of his bathroom habits or his tendency to walk without assistance or his walker.