Failure to Revise Care Plans for Catheter Care and Fall Prevention
Penalty
Summary
The facility failed to revise and update care plans for multiple residents in accordance with their changing clinical needs and current standards of care. For two residents with indwelling urinary catheters, the care plans did not include Enhanced Barrier Precautions (EBP) as required. Observations showed that staff provided catheter care without the use of barrier gowns, and administrative staff confirmed that EBP should have been implemented and documented in the care plans. The facility's own policy required that care plan revisions be made by a licensed nurse in collaboration with the interdisciplinary team and communicated to all staff, but this was not followed for these residents. Additionally, a resident with a history of falls and severe cognitive impairment experienced a significant fall resulting in lacerations to the head and ear. The care plan for this resident was not updated to reflect new interventions or changes in status following the fall, and there was no documentation of a post-fall investigation or implementation of resident-centered interventions to prevent recurrence. The facility's policy required care plan updates and specific instructions to staff after adverse events such as falls, but this was not done. The deficiencies were identified through observation, record review, and staff interviews. Staff and administrative personnel acknowledged that care plans should have been updated to reflect current needs and interventions, including EBP for catheter care and fall prevention strategies after an incident. The lack of timely and appropriate care plan revisions was contrary to both facility policy and regulatory requirements.