Failure to Update Care Plans for Fall Mats and Heel Boots
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that reflected physician orders for two residents. For one resident with a diagnosis including mood disorder and a left clavicle fracture, the most recent Significant Change MDS showed cognitive impairment with a BIMS score of 07 and total dependence for all ADLs. A physician order dated 12/31/2025 directed that the resident’s bed be kept in a low position with fall mats. However, the resident’s care plan, dated 12/29/2025, was not updated to include this order, and no related goals or interventions were developed. Multiple observations over several days documented the resident in bed without fall mats, and the DON confirmed that fall mats were not placed at the bedside or in the room, despite her expectation that staff follow physician orders and that such orders be reflected in the care plan. For a second resident with diagnoses including anxiety disorder, chronic pain syndrome, and mild protein-calorie malnutrition, the most recent Significant Change MDS documented severe cognitive impairment with a BIMS score of 99. A physician order dated 1/16/2026 required the resident to wear bilateral heel boots at all times, every shift. The resident’s care plan, dated 10/23/2025, was not updated to reflect this order, and no associated goals or interventions were developed. On multiple observations, the resident was seen in a geri chair without the ordered heel boots. The resident’s oldest daughter reported that the boots were only worn on occasion, despite the family’s expressed concerns to staff. The DON stated that her expectation is for staff to follow MD orders as written and to update the care plan when significant changes occur.
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