Failure to Update and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three out of five residents reviewed during an abbreviated survey. For one resident with multiple diagnoses and moderate cognitive impairment, there was no documented fall risk or actual fall care plan in place before or after the resident experienced an unwitnessed fall that resulted in skin tears. The incident report noted the bed was in the lowest position and the call bell was within reach, but there was no evidence of a care plan addressing fall risk or interventions to prevent future falls. Interviews with nursing staff and the DON confirmed that care plans should have been updated to reflect the fall and any resulting injuries, but this was not done. Another resident, admitted with a history of impaired mobility and at risk for pressure injuries, developed an eschar on the left heel. Although the presence of the eschar was documented in a nurse's progress note, the resident's care plan was not updated to reflect the new pressure injury, its measurements, or tracking. The responsible RN acknowledged that the care plan should have been updated with this information but confirmed it was not completed. The facility's policy requires that care plans be updated with measurable objectives and interventions when new issues arise, but this was not followed in this case. A third resident, who required assistance due to lower extremity impairment, had a care plan that was not updated to reflect a change to two-person assistance for all cares after a meeting with the resident's representatives. The DON and Administrator both confirmed that the care plan did not include this updated intervention, despite the change being made to ensure the resident's safety. The lack of timely updates to care plans for these residents demonstrates a failure to ensure that services were provided to maintain each resident's highest practicable physical, mental, and psychosocial well-being, as required by facility policy and regulation.