Failure to Develop and Implement Comprehensive Care Plans for Falls and Incontinence
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to falls and incontinence management. For one resident with a history of hemiplegia, hemiparesis, cerebrovascular accident, and a high risk for falls, the care plan did not include a post-fall intervention after the resident experienced an actual fall. Despite the facility's policy requiring immediate reassessment and care plan updates following a fall, no post-fall care plan was created. Staff interviews confirmed that the process was not followed, and the lack of a post-fall care plan meant that new interventions to prevent further falls were not implemented. Another resident, admitted with diagnoses including anxiety disorder, bipolar disorder, neuropathy, and psychosis, did not have a care plan addressing bowel and bladder incontinence management or retraining. The resident's assessment indicated a need for assistance with activities of daily living, but the care plan failed to include interventions for incontinence. The MDS Coordinator and DON both acknowledged that a comprehensive care plan should have been developed to address these needs, as required by facility policy. Facility policies reviewed during the investigation specified that care plans must be individualized, comprehensive, and include measurable objectives and timetables to address each resident's medical, nursing, mental, and psychological needs. The policies also required care plans to be updated promptly in response to changes in a resident's condition, such as after a fall or when incontinence is identified. The failure to follow these policies resulted in incomplete care planning for both residents.