Failure to Timely Revise Care Plans After Falls and Pressure Ulcer Events
Penalty
Summary
The facility failed to revise and update care plans in a timely manner for two residents who were reviewed for falls and pressure ulcers. For one resident with diagnoses of malignant neoplasm of the lung and brain, and moderate cognitive impairment, multiple falls occurred over a period of time. Each fall investigation identified specific interventions such as increased assistance during transfers, regular toileting intervals, use of call lights, 15- or 30-minute safety checks, and environmental modifications like fall mats and visible signs. However, these interventions were not consistently or promptly incorporated into the resident's care plan following each incident, despite being identified as necessary in fall investigations and interdisciplinary team (IDT) reviews. Additionally, another resident with dementia and Parkinson's Disease, who was at risk for pressure ulcers and had existing skin breakdown, did not have their care plan updated to reflect new interventions after a skin integrity event. The event identified the need for offloading heels with pillows and boots, but these interventions were not added to the care plan. The care plan also lacked clarity regarding the measurement units for wounds and did not specify all required interventions for pressure ulcer prevention and management. Interviews with facility staff revealed a lack of clarity and accountability regarding who is responsible for updating care plans after new interventions are discussed or implemented. Both nursing and administrative staff indicated they were either unaware of their responsibilities or had not received training on revising care plans, resulting in delays and omissions in care plan updates. The facility's own policy requires timely care plan revisions when there are changes in condition or interventions, but this was not followed in the cases reviewed.