Failure to Update Care Plan After Fall and New Medical Orders
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address all of a resident's medical needs and preferences. Specifically, after a resident with a history of stroke and morbid obesity experienced a fall from a wheelchair during van transport, no fall incident report was completed, and no new interventions were added to the care plan. The Director of Nursing acknowledged that the event was initially considered a motor vehicle accident rather than a fall, resulting in the omission of required post-fall assessments and care plan updates. Additionally, the care plan did not reflect the resident's preference for sitting on multiple items in the wheelchair, such as a dycem, various cushions, sheepskin, and a bath blanket, nor did it mention the use of a lumbar back support, despite these being regularly used and observed by staff and confirmed by the resident. Further, a physician's order for the resident to bear weight on the right foot in a CAM boot was not incorporated into the care plan or the CNA Kardex. These omissions demonstrate that the facility did not update the care plan to include new medical orders or the resident's specific needs and preferences, as required by facility policy and standard care protocols. The lack of documentation and care plan updates following the fall and the introduction of new medical equipment contributed to the deficiency identified during the survey.