Failure to Implement Comprehensive Care Plans and Supervision
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents, resulting in significant deficiencies. For one resident with a history of traumatic subdural hemorrhage, repeated falls, cognitive impairment, and poor safety awareness, the care plan included interventions such as sitters at bedside and 1:1 staff supervision. However, staff did not consistently implement these interventions, and the resident experienced multiple unwitnessed falls when left unsupervised. Documentation and interviews revealed that sitters were only provided when extra staff were available, and there was no clear duration or end date for the intervention in the care plan. Staff often left the resident unsupervised, especially during breaks, and did not always ensure another staff member was present to supervise the resident, despite the resident's high risk for falls and recommendations from the nurse practitioner for continuous supervision. The resident suffered several falls, including incidents where staff stepped away from the bedside or were not assigned to supervise, resulting in the resident being found on the floor. One of these falls led to a new subacute subdural hematoma, requiring hospitalization and admission to the neurological intensive care unit. Upon return to the facility, the resident continued to be left unsupervised at times, and the care plan interventions were not reliably followed. Staff interviews confirmed that supervision was inconsistent and dependent on staffing availability, and that the care plan interventions were sometimes copied directly from incident reports without specifying implementation details or timeframes. For another resident with a seizure disorder, the facility failed to schedule a neurology consultation as ordered by the physician and indicated in the care plan. The staff member responsible for scheduling follow-up appointments was unaware of the order and did not arrange the necessary consultation. This failure to implement the care plan intervention left the resident without the required specialist evaluation for seizure-like activity. The process for scheduling appointments relied on an appointment slip system, which was not followed in this case, resulting in the omission.