Failure to Individualize Resident Care Plans Following Falls
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, as evidenced by care plans that contained generic interventions not tailored to each resident's specific health needs and functional status. For one resident with dementia and impaired mobility, the care plan remained largely unchanged over multiple quarterly reviews, despite several documented falls, including incidents resulting in a skin tear and a hematoma that required hospitalization. The interventions listed were broad and not specific to the resident's evolving condition, and there was no evidence of new or revised interventions following significant events such as falls. Another resident with Alzheimer's disease, COPD, and diabetes also had a care plan that did not reflect individualized interventions, even after experiencing a fall. The care plan problems and interventions remained static over an extended period, with only minor updates that did not address the resident's changing clinical status or specific needs. Observations indicated the resident was confused and communicated in both English and Spanish, but the care plan did not address these unique communication needs or other individualized factors. Interviews with facility staff, including the Care Plan Coordinator and the resident's physician, revealed a lack of awareness and implementation of specific interventions following falls. The Care Plan Coordinator was unable to identify what interventions were implemented after documented falls, and the physician confirmed that expected fall precautions were not put in place after the initial incident. The facility's policy requires individualized, measurable care plans based on assessment findings, but this was not followed for the residents in question.