Failure to Update Care Plans After Significant Resident Incidents
Penalty
Summary
The facility failed to update and revise care plans with pertinent information following significant changes in the condition and incidents involving two residents. For one resident with Parkinson's Disease, cognitive impairment, and dependence on staff for activities of daily living, there were two documented falls while being transported in a wheelchair. In both incidents, the resident put their feet down while being pushed, resulting in falls and injury, including a hematoma and pain requiring an emergency department visit. Despite these events and documentation in nursing and therapy notes that the resident did not keep feet on the footrests and had poor positioning, the care plan was not updated to include interventions related to the use of footrests to prevent further falls. Another resident with dementia, behavioral disturbances, and a history of trauma experienced a physical altercation with another resident, leading to visible anxiety and fear. Progress notes documented ongoing agitation, anxiety, and behavioral issues, including requests for increased safety measures and a room transfer to address negative interactions. Despite these documented changes and continued behavioral incidents, the resident's care plan was not revised to address the psychosocial impact of the altercation, nor were new interventions added following the room transfer or subsequent behavioral escalations. Interviews with facility staff, including the Unit Manager and Director of Nursing, confirmed that care plans for both residents were not updated with new interventions or information following these significant events. The lack of timely care plan revisions and failure to document appropriate interventions contributed to the deficiency identified during the survey.