Failure to Update Care Plans to Reflect Current Respiratory and Fall-Prevention Interventions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to reflect residents' current clinical status for two residents. For one resident with chronic respiratory failure and dependence on a respirator, physician orders documented a tracheostomy type and size of #8 Portex starting March 19, 2025. However, the resident’s comprehensive plan of care continued to list a trach type and size of 7 XLT-D cuffed under the care area for ineffective airway clearance related to disease process with vent support as needed and trach. In an interview, the Nursing Home Administrator and DON acknowledged that the resident’s trach size and type had changed and that the care plan was not updated, and the DON stated she would expect care plans to be updated timely. For another resident with chronic respiratory failure and hypertension who had an unwitnessed fall on September 24, 2025, the fall report documented an intervention to place bilateral fall mats on either side of the bed. The comprehensive care plan included a focus area for risk of falls with an intervention for bilateral fall mats and instructions to ensure placement every shift, last revised October 21, 2025. Observations of the resident’s room on two separate days did not reveal bilateral fall mats, and a housekeeper reported not having seen any fall mats in the room. The DON stated in interviews that the fall mats had been reviewed and discontinued around the time of the resident’s most recent hospitalization in November 2025 and that she would expect the care plan to be updated, indicating the care plan was not revised to reflect the discontinuation of the fall mats.
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