Failure to Implement and Develop Comprehensive Care Plans for Residents at Risk
Penalty
Summary
The facility failed to implement and develop comprehensive care plans for two residents with significant risks, resulting in deficiencies related to accident prevention and behavioral management. For one resident with schizophrenia, bipolar disorder, and moderate cognitive impairment, the care plan specified that the resident should not be left unattended when out of bed during the day due to a history of unsteady gait and noncompliance with seeking assistance. Despite this, the assigned nurse aide left the resident unattended in their room after providing toileting assistance, which led to the resident falling while attempting to walk to the bathroom. The nurse aide was unaware of the care plan directive and admitted to routinely leaving the resident unattended, indicating a lack of communication and training regarding the resident's specific needs. Another resident, admitted with dementia, multiple fractures, and a history of repeated falls, exhibited behaviors such as flailing arms and fidgeting in bed. Although staff observed and reported these behaviors, there was no documentation or care plan intervention addressing the flailing of arms, despite the potential for self-injury. The care plan focused on the resident's dependence for activities of daily living and transfer needs but did not include strategies to manage or mitigate the behavioral risks. Staff interviews revealed that the director of nursing was not informed of the flailing behavior, and nursing staff did not document these incidents in the resident's record. The facility's failure to identify, document, and address specific behavioral and safety risks in the care plans for both residents resulted in unaddressed hazards and injuries. The lack of communication among staff, absence of thorough documentation, and non-adherence to established care plan interventions contributed directly to the deficiencies cited in the report.