Failure to Timely Develop and Implement Comprehensive Care Plan for Resident with Recent Fall and Surgical Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan within the required timeframe for a resident with significant medical needs. The resident, an elderly female with a history of falls, muscle weakness, lack of coordination, and a recent displaced femur fracture requiring surgical intervention, was admitted for therapy and post-surgical care. Physician orders indicated the need for wound care to a surgical wound on the right femur, and the Minimum Data Set (MDS) assessment documented severely impaired cognition, a recent major orthopedic procedure, and a fracture-related fall prior to admission. Despite these findings, the care plan initiated at admission and later revised did not specifically address the fall with major injury, the presence of fall mats, or the surgical wound requiring wound care. The care plan only included general fall risk interventions such as keeping the call light within reach, prompt response to requests, encouraging appropriate footwear, medication review, therapy evaluations, and placing the bed in a low position. Observations confirmed that fall mats were in use, but these were not reflected in the care plan. Additionally, the care plan for skin integrity addressed a different issue (skin breakdown on the buttocks) and not the surgical wound. Interviews with facility staff, including the Administrator, MDS nurse, and DON, revealed confusion regarding the required timeframe for completing the comprehensive care plan. The MDS nurse and DON initially believed they had 21 days from admission to complete the care plan, but later acknowledged that it should have been completed within 7 days of the comprehensive assessment's completion. At the time of the survey, the care plan remained incomplete, with key interventions still being added after the required deadline.