Failure to Update Care Plans After Resident Decline and Falls
Penalty
Summary
The facility failed to update the Resident Care Plan (RCP) with appropriate interventions following significant changes in residents' conditions. For one resident with severe protein calorie malnutrition, vascular dementia, and difficulty walking, a decline in bed mobility, transfers, and ambulation was documented in a physical therapy discharge summary. Despite this decline, the RCP was not updated to include new preventative measures for pressure ulcer development. The resident subsequently developed a deep tissue injury and a stage 2 pressure ulcer, with the RCP only being updated after these injuries were identified. Another resident, admitted with hypertension, generalized body weakness, and dementia, experienced two unwitnessed falls within a short period. The RCP for this resident identified a risk for falls and included some interventions, but after the falls occurred, no new interventions were added to the care plan to prevent further incidents. The responsible nurse acknowledged that the RCP should have been updated post-fall but could not explain the omission. Interviews with facility staff, including the Director of Nursing Services (DNS) and the MDS Coordinator, confirmed that the care plans were not reviewed or revised in response to significant changes in the residents' conditions or after adverse events. Facility policies required ongoing updates to care plans when new problems arose, but these were not followed in the cases reviewed.