Failure to Update and Communicate ADL Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess, document, and communicate a resident’s Activities of Daily Living (ADL) needs and to ensure the comprehensive, person-centered care plan was timely reviewed and revised after a fall. Facility policy required that care plans be revised as changes in condition dictate and that the interdisciplinary team maintain a comprehensive care plan identifying the highest level of function attainable. A resident (R1) experienced a fall from bed during care when left unattended; an incident note documented that R1 was found on the floor between the bed and the window after being turned on his side and left while the CNA retrieved supplies. The care plan revision completed the following day added an intervention to suction the resident prior to care due to coughing but did not include interventions to prevent rolling from bed during care, instructions for staff to remain with the resident during care, reinforcement of two-person assistance for bed mobility, or accurate documentation of R1’s ADL status and required level of assistance. During interviews, the CNA who provided care at the time of the fall stated that R1 rolled off the bed while she had stepped away and that she was unable to prevent the fall due to the resident’s weight; she also reported that staff lifted the resident from the floor without a mechanical lift because they could not get the lift into the area where the resident was lying. The CNA supervisor stated that staff relied on a binder and verbal communication for care updates and confirmed that R1’s care plan did not include documentation of ADL status, noting that staff unfamiliar with the resident would not know how to safely provide care. The CNA involved did not routinely work on that unit and would not have been familiar with R1’s care needs. The DON and ADON stated they did not directly communicate care plan updates to CNAs and relied on shift report and supervisory staff, and they were unaware that R1’s care plan lacked ADL care instructions. The Administrator stated that nursing leadership was responsible for ensuring care plans were updated and that staff had the information necessary to provide care.
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