Failure to Revise Fall-Risk Care Plan After Room Change and Wander Guard Discontinuation
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with severe cognitive impairment and multiple medical diagnoses, including traumatic subdural hemorrhage, COPD, and muscle weakness. The resident’s MDS dated 10/31/2025 showed severely impaired cognitive skills for daily decisions and a need for staff supervision with hygiene, showering, dressing, transfers, and walking. On 1/10/2026, an eInteract Change in Condition Evaluation documented that an LVN heard a loud sound and found the resident lying on his right side on the hallway floor between his room and the shower room, moaning, with eyes closed and unable to talk, after which the physician ordered transfer to a general acute care hospital. The resident’s care plan for fall risk, dated 1/13/2026, included interventions that the resident be in a room with direct line of sight to the nurse’s station and have a wander guard due to poor safety awareness. Subsequently, the resident was moved from a room near the nurse’s station (room A) to a previous room farther away (room B) and the wander guard was discontinued by physician order on 1/16/2026, but the care plan was not revised to reflect these changes. Observation on 1/27/2026 showed the resident ambulating back and forth in his room without assistance, with the room located seven rooms away from the nurse’s station. Interviews with nursing staff confirmed that the written care plan still indicated the resident should be in direct line of sight of the nurse’s station and have a wander guard, despite the room change and discontinuation of the device. The DON stated that the care plan serves as the nurses’ guideline for resident care and interventions and acknowledged that it should have been updated when the room change occurred and the wander guard was discontinued. The facility’s care plan policy required that care plans incorporate identified problem areas, include measurable goals and timetables, and be reviewed and revised as resident information and condition change, which did not occur in this case.
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