Failure to Update Care Plans After Changes in Resident Condition and Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated to reflect the current needs of several residents following changes in their condition or after significant events such as falls or the development of new wounds. For one resident with a history of stroke, hemiplegia, and impaired mobility, the care plan did not include interventions to keep personal items within reach, despite multiple falls occurring when the resident attempted to reach for items. Progress notes documented repeated falls related to this issue, but the care plan was not revised to address the identified contributing factor. Another resident with hemiplegia, dysphagia, and dementia experienced multiple falls from bed. Although the care plan was updated to include the dates of the falls, no new interventions were added after these incidents. The MDS Coordinator confirmed that she was responsible for revising the care plan but was unaware that new interventions were required following each fall, as outlined in facility policy. Observations confirmed that the resident continued to be at risk, with no additional measures implemented to prevent recurrence. Additional deficiencies were noted for residents with pressure ulcers and new wounds. One resident developed a full-thickness non-pressure wound, and recommendations for wound management, such as limiting sitting time and off-loading, were not incorporated into the care plan. Another resident with new pressure areas and the use of protective boots did not have these changes reflected in the care plan. A resident who required a urinary catheter following urinary retention did not have the care plan updated to reflect this significant change in care needs. These omissions occurred despite facility policies requiring care plans to be reviewed and revised as residents' conditions changed.