Failure to Consistently Implement and Document Care Plan Interventions for Resident Safety
Penalty
Summary
The facility failed to develop and consistently implement care plan interventions for two residents who required a magnetic stop sign across their doorways to minimize the risk of other residents wandering into their rooms. One resident, with diagnoses including legal blindness, a history of falls, and dementia, had a care plan that did not document the use of a magnetic stop sign, despite staff informing the family that this intervention was in place. Multiple observations revealed that the stop sign was either not present or not properly secured, and staff interviews indicated a lack of awareness or understanding regarding the intervention's consistent use and maintenance. Another resident, diagnosed with dementia with psychotic disturbances, major depression, and anxiety, had a care plan that included the use of a magnetic stop sign as an intervention. However, during several observations, the stop sign was not present across the resident's doorway. Staff interviews revealed confusion about whether the intervention was ever implemented or if it was only intended as a temporary measure. The absence of the stop sign was noted despite documentation and staff acknowledgment that it was required for the resident's safety. Throughout the survey, it was observed that the resident who was known to wander continued to do so without purpose or direction, and there were documented incidents of this resident entering the rooms of others, including those who were supposed to be protected by the stop sign intervention. Facility leadership and staff were not consistently aware of the care plan requirements or the status of the interventions, resulting in a failure to follow and document the necessary safety measures as outlined in the residents' care plans.