Failure to Revise Care Plan for Falls, Behaviors, and Naloxone Use
Penalty
Summary
Surveyors identified a failure to revise and implement a comprehensive, person-centered care plan for a male resident with metabolic encephalopathy, bipolar disorder with psychotic features, impaired mobility, muscle weakness, and a history of repeated falls. The resident had a BIMS score of 6, indicating moderate cognitive impairment and impaired safety awareness, and required extensive assistance with ADLs and transfers. Facility fall tracking showed numerous falls over several months, including multiple falls on the same day, reflecting ongoing unsafe transfer attempts, impulsive behavior, and poor safety awareness. Although the care plan identified the resident as high risk for falls and listed general fall-prevention measures, it was not updated with new or individualized interventions despite the continued pattern of falls and documented injuries such as skin tears, abrasions, periorbital bruising, and a laceration. The resident also had a care plan for Risperdal use related to bipolar disorder with severe psychotic features, but this plan only directed staff to monitor and record target behaviors and did not include individualized interventions for behavioral escalation, impulsivity, or aggression during care. The care plan lacked guidance on de-escalation techniques or safe response strategies during combative episodes, even though interviews with a CNA and an LVN confirmed the resident frequently became agitated, attempted to strike staff, and threw himself during transfers. Additionally, the MAR showed an active order for PRN Naloxone (Narcan) nasal spray and a requirement to monitor each shift for signs and symptoms of opioid overdose, yet the care plan did not address suspected overdose or changes in condition requiring emergency response, nor did it provide instructions on when or how to respond to suspected overdose. The DON acknowledged that no new interventions were added to the care plan despite recurrent falls and behavioral concerns, and no care plan policy was provided upon exit.
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