Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were updated and accurately reflected the current needs of residents, as evidenced by the lack of documentation regarding recent falls, transfer status, and the use of side rails for three residents. For one resident, after experiencing a fall that resulted in a hip fracture while being weighed, there was no documentation in the care plan about the fall, fall risk, or the resident's transfer status. The MDS nurse confirmed that care plans should be updated to include such incidents and interventions, but this was not done. Additionally, two other residents had physician orders and assessments indicating the use of side rails for mobility and self-care, yet their care plans did not include any information about side rail use. Observations confirmed that side rails were in use for these residents, and staff interviews indicated that side rails were used for positioning and transfers. The MDS nurse and DON both acknowledged that care plans should reflect the use of side rails and be individualized to each resident's needs, but this was not consistently implemented.