Failure to Update Care Plans for Fall Prevention, Incontinence, and Elopement Risk
Penalty
Summary
The facility failed to revise and update the care plans for two residents following changes in their care needs and health status. For both residents, observations revealed that their beds were in the lowest position and fall mats were in place due to their high risk for falls, and both were wearing briefs due to incontinence. However, their care plans did not document the use of bed positioning, fall mats, or the use of briefs and related interventions. Additionally, one resident's care plan continued to list them as an elopement risk, despite updated assessments showing the resident was fully dependent for activities of daily living and unable to leave the bed independently. Interviews with the DON confirmed that the care plans lacked documentation of these interventions and that the care plans should have been updated to reflect the current needs and approaches for each resident. The absence of these updates meant that staff may not have been aware of the necessary interventions for fall prevention, incontinence management, and elopement risk, as the care plans did not accurately reflect the residents' current conditions and required care strategies.