Failure to Revise Comprehensive Care Plans with Resident-Specific Interventions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to include resident-specific interventions for two residents. For one resident with dementia, Alzheimer’s disease, a history of falls, and impaired cognition, multiple falls occurred, including unwitnessed incidents that resulted in injury and emergency transfer. Despite documented orders for bed and wheelchair alarms, landing pads, and monitoring, the care plans did not include individualized strategies to address the resident’s poor safety awareness or specific fall prevention interventions. The Assistant Director of Nursing acknowledged that the care plans were not person-centered and lacked interventions such as frequent visual checks. For another resident with encephalopathy, muscle weakness, and abnormal gait, the physical therapy (PT) care plan was not updated to reflect the resident’s current ambulation status or to set new, individualized goals after the resident began ambulating with assistance. The PT evaluation and progress reports indicated changes in the resident’s functional abilities, but the care plan did not include updated goals or specify the ambulation schedule and distance. The MDS Coordinator confirmed that the care plan should have been revised to guide staff and track the resident’s progress. Facility policy required that care plans be reviewed and revised upon changes in condition or behavior, but this was not followed. Staff interviews confirmed that the lack of updated, resident-specific interventions in the care plans could delay care and services tailored to the residents’ needs. The failure to revise care plans as required was based on direct observation, interviews, and record review.