Failure to Timely Revise Care Plans After Changes in Condition and Falls
Penalty
Summary
The deficiency involves the facility’s failure to review, update, and revise residents’ care plans after changes in condition. For one resident, surveyors observed the resident in bed using oxygen and later confirmed through record review that the resident had a physician’s order for PRN oxygen at 2 L/min via nasal cannula and a subsequent order for continuous oxygen every shift. Despite these orders, oxygen use was not reflected anywhere in the resident’s care plan. In an interview, the DON acknowledged that the resident was new to oxygen use and agreed that the care plan should have been updated to address oxygen usage. For another resident, the deficiency centered on incomplete and delayed care plan revisions following falls. The resident was admitted in early February and experienced a fall from bed on 2/9, documented by an RN note stating that fall protocol was initiated. A fall-risk care plan had been initiated earlier in the month, and after the 2/9 fall, an intervention was added to monitor side effects of medication; however, the actual fall event and existing risk factors were not fully captured in that revision. A later care plan, initiated after a second fall, documented that the resident was at risk for falls related to history of falls, gait and transfer dysfunctions, fatigue or weakness, new environment, impaired safety awareness/cognition loss, and unsteady gait—conditions that were already present after the first fall. In an interview, the DON confirmed that the fall care plan revised on 2/10 did not capture the actual fall and that care plans are expected to be updated as needed after such events.
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