Failure to Revise Care Plans After Changes in Fall Risk and Transfer Status
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and accurately maintain comprehensive care plans for residents at risk for falls and accidents. One resident with multiple diagnoses including acute respiratory failure with hypoxia, seizures, bipolar disorder, heart failure, reduced mobility, and a history of pulmonary embolism had a fall-focused care plan identifying high fall risk and interventions such as reviewing medications, managing pain, monitoring for acute changes, using gripper socks, and keeping the environment free of clutter. After the resident self-reported an unwitnessed fall while transferring from bed to wheelchair when a wheelchair brake was not locked, the care plan was updated to include brightly colored tape on the wheelchair brakes as a reminder and discussion of risks versus benefits of self-transfers. Later observation showed the wheelchair did not have the colored tape on the brakes but instead had anti-roll bars on both wheels, and the DON confirmed that the care plan had not been revised to remove the tape intervention or add the anti-roll bars despite this change having occurred “a while back.” Another resident with hemiplegia and hemiparesis following stroke affecting the right side, epilepsy, Charcot’s joint of the left ankle and foot, dizziness, severe cognitive impairment, and dependence in most ADLs had a mobility care plan indicating limited physical mobility and an intervention requiring assist of two with a total mechanical lift for transfers. A significant change MDS indicated this resident had falls in the past six months, including a fall with fracture, but the MDS section stated no falls in the last six months and no falls with fracture. A NA reported that the resident had been self-transferring to the wheelchair multiple times during a shift and, upon reviewing the care plan, saw that it still required a total mechanical lift, prompting the NA to seek clarification. The therapy director and OT stated that the resident’s transfer status had been changed to independent on a specific date, and that therapy recommendations are provided to nursing so the care plan can be updated. The ADON acknowledged that the care plan had not been revised to reflect the change in transfer status after therapy’s recommendation, leaving the written care plan inconsistent with the resident’s current transfer abilities and practice.
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