Failure to Revise Care Plan After Falls and Inadequate Pain Assessment for Nonverbal Resident
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was reviewed and revised following a change in condition and after multiple falls for a resident with severe cognitive impairment and significant physical limitations. Despite the resident experiencing three falls in the dining room, including one resulting in a skin tear, the care plan was not updated to include specific interventions to address the risk of falls in that location. The care plan did note a general risk for falls and included standard interventions, but did not reflect the pattern of falls in the dining room or implement targeted strategies to mitigate this risk. Additionally, the facility did not ensure that the resident's care plan included appropriate interventions and methods for assessing and monitoring chronic pain, particularly given the resident's inability to effectively communicate pain. Although the care plan referenced goals for pain management and directed staff to assess for pain, it did not specify the use of validated tools or methods suitable for nonverbal residents. Interviews with staff revealed a lack of familiarity with the care plan's pain management interventions, and staff were unable to describe how they would assess pain in a nonverbal resident, relying instead on general observation and shift reports. The resident involved had a history of dementia, cognitive communication deficits, a recent hip fracture, and required substantial to maximal assistance with activities of daily living. Physical therapy assessments documented significant mobility and balance impairments, as well as poor safety awareness. Despite these documented needs and the occurrence of multiple falls, the care plan was not revised in a timely manner to address the specific risks and needs identified. Staff interviews indicated gaps in communication and understanding of care plan responsibilities, with several staff members unaware of the resident's fall history or the need for care plan updates following incidents.