Failure to Develop and Implement Comprehensive Care Plans for Dementia and Fall Risk
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified needs. For one resident with a diagnosis of unspecified dementia and behavioral disturbances, the care plan did not address dementia-related interventions. Despite multiple medical records and provider notes indicating a history of dementia and the use of antipsychotic medication for behavioral symptoms, the resident's MDS did not code for dementia, and the care area of cognitive loss/dementia was not triggered or addressed in the care plan. The facility's own dementia clinical protocol requires the interdisciplinary team to identify and document resident-centered care plans for individuals with confirmed dementia, but this was not followed in this case. For another resident with a history of spinal surgery, radiculopathy, and spinal stenosis, assessments upon admission identified the individual as a moderate to high risk for falls. The Morse Fall Assessment and nursing observations documented impaired gait, non-ambulatory status, and dependence on a wheelchair or geri-chair for mobility. The resident's MDS triggered the care area of falls, but the care plan did not include any interventions or documentation addressing fall risk. Subsequently, the resident experienced a fall while attempting to use the bathroom independently, resulting in pain and further medical evaluation. Interviews with facility staff confirmed that care plans should have included interventions for both dementia and fall risk based on assessments and diagnoses. Facility policies require comprehensive, person-centered care plans with measurable objectives and interventions derived from thorough assessments. However, these requirements were not met for the two residents, as evidenced by the lack of appropriate care planning and documentation for their specific needs.