Failure to Implement Care Plan Interventions for Falls and Pressure Ulcer Management
Penalty
Summary
Surveyors identified that the facility did not fully implement and maintain care plan interventions for a resident at high risk for falls. One resident with senile degeneration of the brain, muscle weakness, impaired cognition, and a documented high fall risk had a care plan that required a safe environment, call light within reach, and nonskid socks at all times as the resident allowed. Despite multiple prior falls related to self-transfers and added interventions such as nonskid socks, alarms, and safe storage of assistive devices, the resident was observed sitting in a wheelchair wearing plain white socks without nonskid tread. On another occasion, the resident was observed in bed with the call light under the bed and the wheelchair positioned in the resident’s line of sight, contrary to staff’s stated practice of storing the wheelchair out of sight to reduce self-transfer attempts. Surveyors also found that the facility failed to follow physician orders for wound care for a resident with a coccyx wound. The resident, who had chronic respiratory failure, was rarely or never understood, and was dependent on staff for all ADLs, had a physician order directing staff to cleanse the coccyx wound with wound cleanser, pat dry, then apply a mixture of triad and collagen particles to the wound bed and leave it open to air once per day on the day shift. During an observed treatment, an RN entered the room, turned the resident, laid the bed down, removed existing paste from the coccyx area using the pad under the resident, changed gloves, and applied a mixture of collagen and triad with a cotton swab. The RN did not cleanse the wound area before applying the new paste, contrary to the physician’s order. In addition, the facility did not adhere to care plan interventions related to aspiration precautions for the same resident receiving continuous tube feeding. The resident’s care plan required keeping the head of the bed elevated 45 degrees during tube feeding and for one hour after completion. During the observed wound treatment, the RN used the bed remote to lay the bed down without pausing the resident’s continuous PEG tube feeding. The Infection Prevention Nurse later stated that a resident receiving continuous tube feeding should not be laid flat and that staff should follow treatment orders as written by the physician. These observations demonstrated that care plan and physician-ordered interventions for both fall prevention and pressure ulcer management were not consistently implemented as planned.
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