Failure to Update Care Plan After Discontinuing Bed Alarm and Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address all of a resident's medical, nursing, mental, and psychosocial needs. Specifically, the care plan did not reflect the discontinuation of a bed alarm for a resident with a history of falls and severe cognitive impairment, nor did it address a significant fall with major injury that occurred after the alarm was discontinued. The resident, who was dependent on staff for personal hygiene and required maximal assistance with toileting, had a recent history of hip fracture and a severely impaired cognitive level as indicated by a BIMS score of 03. Despite these risk factors, the care plan was not updated to reflect changes in interventions or to document the rationale and monitoring strategies following the discontinuation of the bed alarm and after the resident experienced a fall resulting in a new hip fracture. Interviews with facility staff, including the DON, CNA, and Medical Director, revealed that bed alarms had been discontinued facility-wide based on the belief that they were restraints and not effective in preventing falls. However, there was no documentation in the care plan regarding the discontinuation of the alarm or the implementation of alternative interventions with specific time frames or responsibilities. The acute care plan presented after the fall included frequent visual checks, but did not specify the frequency or timing of these checks. The lack of timely and comprehensive updates to the care plan following significant changes in the resident's condition and interventions contributed to the deficiency.