Failure to Include Elopement and Fall Interventions in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required. For one resident with a history of cerebral infarction, severe cognitive impairment, and high risk for elopement, the care plan did not include any information or interventions addressing the elopement risk, despite assessments and physician notes identifying this risk. Multiple staff interviews revealed a lack of awareness regarding residents at high risk for elopement, even though facility leadership confirmed that this resident was considered high risk. For another resident with a history of falls, moderate cognitive impairment, and significant dependence for activities of daily living, the care plan did not include specific fall prevention interventions such as keeping the bed in a low position or ensuring a fall mat was at the bedside. These interventions were present in the physician's orders but were not reflected in the care plan. Staff interviews indicated an expectation that such interventions would be documented in the care plan, and facility policy required individualized fall prevention plans based on resident risk factors. The deficiencies were identified through record reviews, staff interviews, and policy reviews, which showed that the care plans did not reflect all identified risks and physician-ordered interventions for the residents. This lack of comprehensive care planning could result in staff not being aware of or implementing necessary interventions to address the residents' medical, nursing, and psychosocial needs.