Failure to Develop and Implement Care Plans for Discharge Planning and Fall Prevention
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in deficiencies related to discharge planning and fall prevention. For one resident with a history of cerebral infarction, hemiplegia, and other significant medical conditions, there was no care plan focus area addressing her request to be discharged to the community, despite her being cognitively intact and having discussed her desire for independent living with staff over six months prior. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's discharge wishes, and no documentation or care plan was initiated to address her request. For another resident with multiple diagnoses, including a high risk for falls as indicated by a fall risk assessment, the facility failed to implement a physician-ordered intervention for a fall mat to be placed at the bedside. Despite the care plan and physician orders specifying the need for a fall mat, repeated observations over several days confirmed that no fall mat was present. Staff interviews corroborated that the intervention was not in place as required.