Failure to Revise Care Plans for Fall Prevention and Smoking Supervision
Penalty
Summary
The facility failed to revise and update the care plans for two residents in accordance with their changing needs and interventions. For one resident with a history of cerebrovascular accident and hemiparesis, who was cognitively intact and used a wheelchair, a fall occurred resulting in a forehead laceration that required hospital treatment. Although a scoop (perimeter) mattress was implemented as an adaptive device to prevent further falls, the care plan was not updated to reflect this intervention. This omission was confirmed by both clinical record review and staff interview. For another resident admitted with COPD and an adjustment disorder, the care plan contained conflicting interventions regarding smoking. While the care plan identified the need to eliminate respiratory irritants such as cigarette smoke, it also documented the resident's preference and designation as a safe smoker, allowing smoking in designated areas at scheduled times. This inconsistency in the care plan was identified through review of the clinical records and care plan documentation.