Failure to Develop and Implement Comprehensive Care Plans for Fall Risk and ADL Assistance
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to fall risk management and adherence to required assistance for activities of daily living. One resident with chronic obstructive pulmonary disease, cervical radiculopathy, and congestive heart failure had a history of falls and was identified as having impairments in strength and mobility. Despite a fall and subsequent risk assessment indicating the resident was at risk for falls, the care plan did not reflect this risk or include appropriate interventions until after another fall occurred. Documentation revealed that the fall risk care plan had previously been marked as resolved without clear justification, and staff responsible for care planning were unaware of the absence of an active fall risk plan prior to the incident. Another resident with adjustment disorder, anxiety, and psychotic disorder was care planned to require two staff members for all direct care due to behavioral concerns. Observations showed that this intervention was not consistently followed, with nurse aides providing care alone on multiple occasions. Interviews with staff indicated a lack of awareness regarding the continued need for two-person assistance, and staffing patterns made it difficult to comply with the care plan directive. The care card for the resident continued to specify the need for two staff members, but this was not adhered to in practice. Facility policy required the development and ongoing updating of individualized care plans, with staff expected to follow the most current plan of care. In both cases, the facility did not ensure that care plans accurately reflected residents' needs or that staff consistently implemented the specified interventions, leading to deficiencies in resident care.