Failure to Update and Revise Care Plans After Changes in Resident Status and Falls
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect the current care needs for two residents. For the first resident, who had severe cognitive impairment and multiple diagnoses including dementia, Alzheimer's disease, and Parkinson's disease, there were repeated falls over a two-month period. Despite multiple falls and high fall risk assessments, the care plan was not updated with new interventions after several incidents. Documentation showed that interventions were either not implemented or not recorded after many of the falls, and post-fall investigation tools were often left incomplete. The care plan was only updated after a significant delay, and did not reflect the ongoing changes in the resident's condition or the interventions that were (or should have been) put in place following each fall. For the second resident, who was also severely cognitively impaired and had a history of falls, the care plan was not updated to reflect changes in transfer status, fall prevention interventions, or hospice status. After a change in transfer method and two falls—one resulting in a hip fracture—there was no evidence that the care plan was revised to include new interventions or to address the resident's current needs. Additionally, the care plan still referenced equipment (an air mattress overlay) that was no longer in use, and did not reflect the resident's re-admission to hospice services. Interviews with staff revealed confusion and inconsistency regarding who was responsible for updating care plans and how interventions were communicated. While some staff referenced the care plan in the electronic medical record to guide care, others were unsure where to find updated interventions. The facility's policy required care plans to be revised as residents' needs changed, but this was not consistently followed, resulting in care plans that did not accurately reflect the residents' current care requirements.