Failure to Revise Person-Centered Care Plan After Recurrent Falls and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive, person-centered care plan related to fall risk for a resident with multiple medical and cognitive conditions. Facility policies required individualized care plans with measurable goals, ongoing assessment, and interdisciplinary review and revision after significant changes in condition, hospitalizations, and recurrent falls. The resident had anemia, hypertension, peripheral vascular disease, renal failure requiring dialysis, anxiety, depression, and schizophrenia, and required supervision for toileting, showering, dressing, transfers, and walking, with a BIMS score of 9 indicating moderate cognitive impairment. Nursing documentation showed multiple falls, including a fall from a dining room chair with minor bleeding, a stumble to the knees without injury, and a subsequent hospitalization where the resident was diagnosed with a hemoglobin of 6.6 and a subdural hematoma, followed by readmission to the facility. Despite these events and documented weakness, decreased safety awareness, and repeated falls, the resident’s care plan did not include specific, individualized interventions to address progressive functional decline or increased supervision needs. The resident was care planned for fall risk and a decline in mobility, with therapy services initiated, but interventions such as encouraging wheelchair use, therapy referrals, and a pharmacy consult were minimal and were not revised after subsequent falls. After readmission from the hospital, there was no evidence that the interdisciplinary team updated the care plan to include enhanced safety measures, increased monitoring, or alternative interventions, and no formal neurological assessments were implemented. Staff interviews confirmed that, aside from keeping the bed in a low position and performing routine safety checks and general nursing assessments, no additional individualized interventions or care plan updates were put in place following the resident’s recurrent falls and hospitalization for subdural hematoma.
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