Failure to Timely Update Care Plans for Falls and Pressure Ulcers
Penalty
Summary
The facility failed to review and revise care plans in a timely manner for multiple residents, resulting in deficiencies related to falls and pressure ulcers. One resident with hemiplegia, chronic kidney disease, and osteomyelitis developed a right heel blister that progressed to a deep tissue injury, but the care plan was not updated to reflect the wound or interventions until after the resident returned from a hospital transfer. The facility's own policy required the interdisciplinary care plan to identify risks and interventions for skin impairment, but this was not followed, and the DON was unaware of the wound until the hospital admission. Another resident experienced two separate incidents involving falls and altercations with a roommate, including being struck by a wheelchair and sustaining injuries such as a hematoma and pain. Despite these events, the care plan was not revised after the first incident to include measures to prevent further injury or address the risk of resident-to-resident altercations. The care plan was only updated after the second incident, and the DON confirmed the lack of documentation regarding the previous altercation. Additionally, a resident with dementia and a history of aggressive behaviors, including harming others and refusing medications, was recommended for 1:1 supervision and IM medication by a psychiatrist. However, the care plan was not updated to reflect these recommendations or new orders. Another resident with a stage 2 pressure ulcer of the heel had a treatment plan that included offloading pressure, but this intervention was not included in the care plan. These failures to update care plans were confirmed by staff interviews and record reviews.