Failure to Implement and Update Care Plans for Fall Prevention and Smoking Safety
Penalty
Summary
The facility failed to ensure that a resident's care plan for fall prevention was reviewed, updated, and implemented as required, and also failed to assess and supervise residents who engaged in smoking to prevent injury. For one resident with a history of falls and cognitive impairment, the care plan specified interventions such as keeping the bed in the lowest position and placing a fall mat on the right side of the bed. However, multiple observations showed the bed was not kept in the low position and the fall mat was consistently placed on the left side, contrary to the care plan. Staff interviews revealed that they were unaware of the specific care plan instructions regarding the placement of the fall mat and the bed position, indicating a lack of communication and implementation of the care plan interventions. Additionally, two residents who were known to smoke were not properly assessed for their ability to smoke safely, and their care plans did not include any focus or interventions related to tobacco use. One resident had a documented history of smoking and continued to smoke, with supplies reportedly locked up with a nurse, but there was no record of a smoking safety assessment. The other resident was also identified as a current smoker, but their care plan lacked any mention of tobacco use, and staff were unaware of their smoking status. Interviews with staff, including nursing assistants and LPNs, confirmed that they were not aware of any current smokers in the facility and had not received guidance from the care plans regarding supervision or interventions for smoking. The lack of updated and implemented care plans for both fall prevention and smoking safety resulted in inconsistent interventions and unmet care needs for the residents involved. The facility's interdisciplinary team was not aware of the deficiencies in care plan implementation or the need for updated assessments and interventions for residents who smoked. This deficiency was noted as a repeat issue from a previous survey.