Failure to Develop Individualized, Measurable Care Plan After Change in Condition
Penalty
Summary
The facility failed to develop an individualized care plan for a resident following a change in condition, specifically after the resident exhibited behaviors such as kneeling and placing themselves on the floor, despite being identified as a high fall risk. The resident had a history of severe cognitive impairment, dependence on staff for activities of daily living, and diagnoses including metabolic encephalopathy, a right ulna fracture, and unsteadiness on their feet. The care plan in place noted the resident's risk for falls and listed general interventions such as anticipating and meeting needs, but did not specify the type or frequency of supervision or monitoring required. Further review revealed that after the resident began placing themselves on the floor, the care plan was updated to include frequent visual monitoring and placement near the nursing station for closer supervision. However, the care plan did not define how often this monitoring should occur. Staff interviews confirmed that 1:1 monitoring was implemented and that the resident was kept near the nurse's station, but the care plan lacked measurable, specific timetables for these interventions. The Director of Nursing acknowledged that the care plan should have included more specific monitoring intervals, especially given the resident's behaviors.