Failure to Timely Update Baseline Care Plan for Fall Risk and Transfer Needs
Penalty
Summary
The facility failed to develop and implement an adequate baseline care plan within 48 hours of admission for a resident with significant fall risk factors. The resident, who had hemiplegia and hemiparesis following a stroke, was assessed as being at moderate risk for falls according to the Morse Fall Scale. Despite this, the temporary care plan did not include a focus area or interventions for fall prevention, nor did it address a toileting program for the resident's incontinence. The care plan also failed to specify the resident's transfer status, even though therapy notes and recommendations indicated changes in required transfer methods and equipment. Multiple staff interviews and document reviews revealed that the care plan was not updated in a timely manner to reflect changes in the resident's condition and therapy recommendations. Nursing assistants were unable to locate current transfer instructions in the electronic health record or on the therapy clipboard, leading to confusion about the appropriate transfer method. The physical therapist confirmed that updated transfer recommendations were communicated to nursing, but these were not incorporated into the care plan as expected. The director of nursing acknowledged that the care plan had not been updated to include fall risk, fall prevention interventions, or the resident's new transfer status. The facility's own policy requires that a baseline care plan be developed within 48 hours of admission, including interventions to address health and safety concerns such as fall risk. However, the resident's care plan did not meet these requirements, as it lacked essential information needed to prevent decline or injury. This failure resulted in staff not having access to up-to-date instructions for safe care, particularly regarding fall prevention and transfer assistance.