Failure to Implement Care-Plan Interventions for Fall Prevention, Assistance Level, and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a male resident with a history of cerebral infarction, left knee contracture, hemiplegia of the left nondominant side, need for assistance with personal care, and cognitive communication deficit. His quarterly MDS showed a BIMS score of 8/15, indicating moderate cognitive impairment, and documented that he required substantial/maximal assistance with toileting hygiene and rolling. His care plan and Kardex identified him as at risk for falls due to hypertension and a prior fall, with interventions including bilateral fall mats at both sides of the bed, staff x2 assistance for bed mobility and toilet use, and bowel incontinence management with checks every two hours and assistance with toileting as needed. On the survey date, observation at 10:09 a.m. showed the resident lying on a scoop mattress with no fall mats on either side of the bed, despite the care plan and Kardex specifying bilateral fall mats. Later observation at 11:07 a.m. revealed the resident’s brief was soiled and the blue line indicator showed it was wet, although the resident denied feeling wet. Multiple CNAs interviewed between approximately 11:15 a.m. and 11:45 a.m. reported they had not checked or changed the resident since the start of their shifts at 6:00 a.m., and one CNA assigned to the resident stated she arrived late and had not been in the resident’s room prior to the surveyor’s observation. The assigned CNA subsequently changed the resident’s soiled brief alone at 11:25 a.m., and the soiled brief contained a bowel movement. Further interviews and record review showed that the Kardex required staff x2 for bed mobility and toilet use, and incontinent care at least every two hours with application of moisture barrier after each episode. The assigned CNA initially stated the resident was a one-person assist for incontinent care and was unsure what the Kardex indicated, then acknowledged after review that the resident required two-person assistance and that she was supposed to check and change him every two hours. She reported last changing him at 11:00 a.m. and stated she had never seen a fall mat at the bedside. Observation confirmed the fall mat was stored in the resident’s closet. Nursing leadership and other staff acknowledged that the care plan had not been updated to reflect changes such as the use of a scoop mattress and that the resident’s care plan had not yet been reviewed for personalization, resulting in care that did not follow the documented interventions for fall prevention, assistance level, and incontinence management.
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