Failure to Accurately Complete and Update Care Plans for Falls and Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that care plans were completed accurately and updated to reflect current interventions and behaviors for two residents. For one resident with diagnoses including viral hepatitis, anxiety, and arthritis, a fall investigation revealed that the resident had rolled off the bed and fallen. Although a mattress was placed beside the bed as a fall intervention, this measure was not documented in the resident's care plan. The Director of Nursing confirmed that the intervention was not included in the care plan and stated that both the mattress and 15-minute checks were considered temporary and were no longer in place, with the mattress never having been listed as an intervention. For another resident with anxiety and viral hepatitis, who exhibited behavioral symptoms such as confusion, forgetfulness, and difficulty remembering, the care plan addressed some behavioral interventions but did not include information about the resident's ongoing behaviors of accusing staff of false accusations and not listening, which had been occurring for at least a year and had increased in frequency. The Director of Nursing confirmed that these behaviors were not documented in the care plan. Facility policy required care plans to be revised as the resident's condition changed and to identify problem areas and risk factors, but this was not followed in these cases.