Failure to Implement and Document Comprehensive Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to implement and document comprehensive care plans for multiple residents at high risk for falls and requiring increased supervision. For one resident with end-stage heart failure, chronic kidney disease, and on hospice care, the care plan required hourly safety rounds and use of a motion sensor due to high fall risk and impaired mobility. Despite these interventions, there was no evidence of consistent hourly rounding or toileting care, and the resident was found deceased on the floor with a detached call light and feces present. Staff interviews revealed that assigned personnel took extended breaks without proper communication, were unaware of the resident's need for increased supervision, and failed to document care or the circumstances of the resident's death in the medical record. Another resident with dementia, muscle weakness, and high fall risk had care plan interventions including hourly checks in common areas, use of a motion sensor, and scheduled toileting. Documentation showed that these interventions were not consistently implemented, with gaps in toileting hygiene records and a fall occurring when the motion sensor failed to detect movement due to improper placement. Staff interviews indicated a lack of awareness of specific care plan interventions and infrequent review of care plans, leading to missed or improperly executed fall prevention strategies. A third resident with Parkinson's disease and a history of multiple unwitnessed falls had care plan interventions for motion sensor use, frequent checks, and toileting assistance. Despite these interventions, the resident experienced repeated falls, including one resulting in a hip fracture and hospitalization. The care plan was not updated after the fall, and incident reports were not completed. Staff and leadership interviews confirmed a lack of documentation and monitoring of the effectiveness of hourly checks, as well as confusion regarding which residents required increased supervision. The facility also lacked policies for supervision, call light use, and response to untimely death, contributing to the deficiencies.