Failure to Update Care Plans After Falls and Pressure Ulcer Development
Penalty
Summary
The facility failed to update and revise care plans for three residents after significant changes in their conditions, specifically following falls and the development of new pressure ulcers. For one resident with severe cognitive impairment and a history of falls, multiple falls were documented within a short period, but the care plan was not updated to reflect these incidents or to add new interventions. Another resident, who had mild cognitive impairment and was at risk for pressure ulcers, developed new stage 2 pressure ulcers in-house, yet the care plan lacked specific details such as the type and location of the ulcers and did not include interventions to prevent new pressure ulcers from developing. Additionally, this resident experienced multiple falls, but the care plan was not revised to address these events or to implement new fall prevention strategies. A third resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease and a history of falls, experienced several falls, one of which resulted in injury and hospitalization. Despite these incidents, the care plan was not promptly updated to reflect the new falls or to add or revise interventions. Staff interviews revealed that care plans were not consistently updated immediately after significant events, and there was confusion among staff regarding who was responsible for updating care plans and what information should be included. Some staff relied on the charting system to check for interventions, but care sheets were not available, and there was a lack of clear policy guidance on care plan revision. The facility was unable to provide a policy regarding care plan revision, and corporate staff did not supply requested policies in a timely manner. The lack of timely and comprehensive updates to care plans after significant changes in residents' conditions, such as falls and the development of pressure ulcers, was identified through observations, record reviews, and staff and resident interviews. This deficiency affected at least three residents in a facility with a census of 26 residents.