Failure to Develop Care Plans After Fall and Abrasion Events
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for identified conditions, as required by its own policy. The facility’s policy titled "Care Plans, Comprehensive Person-Centered" (revised December 2016) states that a comprehensive care plan with measurable objectives and timetables must be developed and implemented for each resident to meet physical, psychosocial, and functional needs, and that the IDT must review and update the care plan when there is a significant change in condition. For one resident with severe cognitive impairment, an eINTERACT Change in Condition Evaluation dated 11/26/25 documented an unwitnessed fall. Review of this resident’s plan of care showed no care plan was developed to address the actual fall on that date. During interviews and concurrent record reviews, RN 2 and the DON both verified that there was no care plan for the fall and stated that the licensed nurse should have created one with appropriate interventions and goals. For another resident, also with severe cognitive impairment, a Post Fall IDT note dated 1/12/26 documented an upper back abrasion. Review of this resident’s plan of care showed no care plan was developed to address the upper back abrasion. In interviews with RN 2 and the DON, both confirmed that there was no care plan addressing the abrasion. RN 2 stated that the licensed nurse should have created a care plan so that interventions would be implemented and goals created, and the DON stated that a care plan should have been completed to address the resident’s upper back abrasion. These findings demonstrate that, for two of five sampled residents, the facility did not develop care plans reflecting their individual care needs following identified events and conditions, contrary to the facility’s written policy.
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