Failure to Include Fall-Prevention and Antianxiety Interventions in Resident Care Plans
Penalty
Summary
Surveyors identified that the facility did not develop and implement complete, individualized care plans for two residents following changes in condition and treatment. For one resident with a history of stroke, unsteadiness on feet, and muscle weakness, records showed the resident fell from bed while sleeping and was hospitalized. Progress notes documented that new fall prevention interventions would be determined upon the resident’s return and that the care plan was reviewed and updated. The revised care plan referenced the fall and directed staff to assist with mobility and maintain a clutter-free environment, but it did not include the specific intervention that staff had instructed the resident to follow: keeping the bed in the lowest position when asleep. During interviews, the resident confirmed staff had given this instruction, and an LPN and CNA both stated that such a bed-positioning intervention should appear in the care plan, but it was not present. For another resident with severely impaired cognition, non-Alzheimer’s dementia with behavioral disturbances, anxiety, and depression, the MDS and electronic health record documented an order for antianxiety medication and described the behaviors the resident exhibited when anxious. A progress note also described the resident’s anxiety behaviors and indicated they had not been recently observed. However, the resident’s care plan, although it listed an anxiety disorder, did not include the ordered antianxiety medication, did not specify the resident’s anxiety behaviors for staff to monitor, and did not outline any non-pharmacological interventions for staff to attempt. In interviews, an LPN and CNA indicated that the antianxiety medication, target behaviors, and related interventions should be included in the care plan, and the DON stated that care plans should be updated to accurately reflect care based on physician orders, consistent with the facility’s comprehensive care plan policy.
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