Failure to Develop and Update Comprehensive Care Plans After Clinical Events
Penalty
Summary
A deficiency was identified in the facility's development and implementation of comprehensive, person-centered care plans for residents. Specifically, for three residents reviewed, the facility failed to initiate or update care plans in response to significant clinical findings and incidents. One resident, admitted with multiple diagnoses including diabetes mellitus and end stage renal disease, was assessed as high risk for falls upon admission, but there was no documented evidence that a fall risk care plan was initiated. This resident later experienced a fall when attempting to self-transfer from bed to chair. Another incident involved two residents who were roommates. One resident reported being struck by the other following a verbal disagreement. Although both residents had existing care plans noting potential for abuse, there was no documentation that these care plans were updated to reflect the incident or that new interventions were implemented. The resident who was struck was relocated for safety, but the care plan documentation did not reflect this event or any subsequent changes in interventions. Interviews with facility staff, including registered nurses and directors of nursing, confirmed that care plans should be initiated or updated when assessments trigger specific care areas or after incidents occur. However, in these cases, the required updates and documentation were not completed as per facility policy and regulatory requirements. The lack of timely and appropriate care plan development and revision was observed through record reviews and staff interviews during the survey.