Failure to Implement Care Plan Interventions for Fall Prevention and Eating Assistance
Penalty
Summary
Surveyors identified a failure to implement comprehensive care plan interventions for multiple residents, resulting in care not being provided as planned. One male resident with multiple sclerosis, dementia, anxiety, weakness, a history of repeated falls, and other psychiatric diagnoses had a care plan focus on limited physical mobility and fall risk, with specific interventions including use of a pillow or rolled blanket to define bed borders and a wedge or body pillow to prevent him from leaning or falling from the bed. On multiple observations over several days, the resident was seen lying in bed leaning to the right side without any pillow, blanket, or wedge in place, and at one point his right arm and shoulder were off the side of the mattress while a blue wedge was observed on the bedside table instead of in use on the bed. Another female resident with dementia, osteoporosis, and multiple sclerosis had a care plan identifying her as at risk for falls due to a high desire for independence, challenged balance and coordination, low safety awareness, and a tendency to lean forward when propelling herself in a wheelchair. Following an incident where she was found sitting on the floor after sliding while attempting to transfer from bed to wheelchair without staff assistance, the plan of care was updated to include a non-slip dycem pad to the side of her bed. However, during multiple observations, no dycem was found on or under the sheets on the exit side of the bed. The resident stated she did not know what a dycem was and that there was none on her bed. A CNA and an LPN both reported they had not seen a dycem on the bed and were unaware of the intervention, despite the Kardex indicating its use, and staff interviews confirmed that the dycem was not being implemented as planned. A third resident with type 2 diabetes mellitus had a care plan indicating an ADL self-care performance deficit, with a goal to improve self-care and an intervention specifying that she required assistance with eating. Progress notes documented that she required assistance with feeding and was only eating bites of her meals. Despite this, facility documentation for multiple dates recorded her as independent with eating or needing only setup assistance. Several LPNs and a CNA reported that the resident always ate in her room and generally did not receive assistance with eating, although some staff had noticed she did not eat well and seemed to need help. One LPN stated she did not know the care plan required assistance with eating and another reported the resident did not require such assistance. During observation, the resident was seen in her room attempting to eat independently, struggling to scoop food onto her fork and unable to cut her chicken, with no staff present to assist her, contrary to the care plan intervention.
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