Failure to Implement Professional Standards and Care Plan Updates
Penalty
Summary
Facility staff failed to follow professional standards of care for two residents. For one resident with a history of inappropriate sexual behaviors, the nurse practitioner recommended interventions such as providing visual aid materials and allowing private time to help manage the behaviors. However, these recommendations were not implemented, and the care plan was not updated to reflect these interventions. The nurse practitioner was not informed that her recommendations had not been carried out, and the care plan only included 15-minute checks and instructions to notify the physician if behaviors continued, omitting the suggested behavioral interventions. Facility policy required that care plans be updated and that staff notify clinical leadership if interventions could not be implemented, but this was not done. For another resident who experienced an unwitnessed fall, staff failed to complete and document all required neurological checks following the incident. The facility's fall management procedure required consistent neuro checks after a fall, but documentation showed that these checks were missing on some days. The Director of Nursing confirmed the absence of neuro check documentation, indicating that the facility did not follow its own procedures for post-fall assessment and monitoring.