Failure to Address Resident's Bed Height Preference in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop a person-centered comprehensive care plan that addressed all of a resident's needs, specifically the resident's preference to keep the bed in a high position despite being at high risk for falls. Observations showed the resident resting in bed with the bed in the highest position on multiple occasions, with the bed control device within reach and no staff present. The resident, who had diagnoses including vascular dementia and right-sided hemiplegia/hemiparesis following a stroke, was assessed as severely cognitively impaired and at high risk for falls. The care plan in place addressed fall risk related to right-sided deficits but did not address the resident's expressed preference for bed height. Interviews with staff confirmed that the resident had been educated about the safety concerns of keeping the bed elevated but continued to adjust it to the highest position. The Assistant Director of Nursing acknowledged that the clinical record lacked a care plan addressing this specific preference. Facility policy required comprehensive care plans to be reviewed and updated based on changes in the resident's condition or newly developed issues, but this was not done in this case.