Failure to Review and Revise Care Plan After Wheelchair Sliding Incident
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan by the interdisciplinary team after a change in condition, as required by facility policy and regulation. The resident had diagnoses including constipation, chronic pain syndrome, a history of falling, and a Minimum Data Set showing moderately impaired cognition. The existing care plan for an actual fall, initiated months earlier, included interventions such as keeping personal items within reach, neuro checks, physical therapy, and routine rounding. On a specific date and time, an occupational therapist assistant (OTA) observed the resident sliding from a wheelchair to the floor, reported the incident to an LPN, and documented the event on a facility statement form. The RN supervisor on duty acknowledged being notified that the resident had slid from the wheelchair to the floor and stated that a full body assessment was performed, with no injuries, trauma, or pain reported by the resident. However, the RN supervisor also stated they did not document the sliding incident and did not update the resident’s care plan. There was no documented evidence that the care plan was reviewed or revised with new interventions following this event, and no documentation of a team meeting to discuss the incident. The DON reported being unaware of the sliding incident and stated that the RN supervisor should have completed an incident report and updated the care plan. This lack of documented care plan review and revision after the resident slid from the wheelchair to the floor formed the basis of the cited deficiency under 10 NYCRR 415.11.
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