Failure to Update Comprehensive Care Plans After Resident Falls
Penalty
Summary
The facility failed to review and revise the person-centered, comprehensive care plans for three residents who experienced multiple falls within a 30-day period. For one resident, the care plan was found to be completely blank with no problems or interventions listed, despite recent falls and a medical history including pneumonia, metabolic encephalopathy, hypertension, chronic pain, heart disease, anxiety disorder, muscle weakness, unsteadiness, lack of coordination, and COPD. Another resident's care plan had not been updated since the previous year, even though the resident had a history of Huntington's disease, unsteadiness, muscle weakness, difficulty walking, and multiple recent falls. The third resident, with diagnoses including hypertension, heart disease, anxiety disorder, Alzheimer's disease, muscle weakness, chronic pain, arthritis, and COPD, also had a care plan that had not been updated since the previous year despite experiencing several falls. Interviews with facility staff revealed that the responsibility for updating care plans was shared between nursing and the MDS coordinator. The MDS coordinator acknowledged that care plans were not updated in a timely manner due to workload and staffing limitations, and that this issue had been communicated to the DON without resolution. The ADON and administrator both confirmed that the expectation was for care plans to be updated after falls were discussed in morning meetings, but this was not occurring as required. Record reviews confirmed that the facility's policy required the interdisciplinary team to develop and implement comprehensive, person-centered care plans that are revised as residents' conditions change. Despite this policy, the care plans for the three residents were not updated to reflect recent falls or new interventions, resulting in incomplete or outdated documentation of care needs and interventions.