Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect specific care needs, leading to a deficiency. Resident 3, who was cognitively intact and had a history of falls, was admitted with a comprehensive care plan that included various interventions to prevent falls. Despite these measures, the resident experienced an unwitnessed fall in her room, resulting in a subdural hematoma and subsequent hospitalization. The care plan did not include the intervention of calling the resident's son when she was restless, which was identified as a calming measure after a previous fall. Interviews with the Assistant Director of Nursing and the Nursing Home Administrator revealed that staff were instructed to call the resident's son to help prevent further falls, but this intervention was not documented in the care plan following the fall on February 1, 2025. The lack of documentation and update to the care plan contributed to the deficiency, as the facility did not adequately revise the care plan to address the resident's specific needs and prevent further incidents.
Plan Of Correction
1. Resident 3's care plan was updated on 2/5/2025 with the intervention to call her son when she is restless to help prevent future falls. 2. An audit was completed by Director of Nursing, or designee, on currently admitted residents with falls occurring in the last 30 days to ensure that interventions put into place were added to the resident's care plan. 3. An education was completed with licensed nursing staff and interdisciplinary team members who edit care plans on the appropriate entering of interventions in the resident's care plan following falls. 4. An audit will be conducted on 5 active residents who have had 1 or more falls to ensure that care plan interventions were added to the resident's care plan appropriately following a fall weekly x 4 weeks, then monthly x 2 months. The results of these audits will be brought to the Quality Assurance Performance Improvement (QAPI) committee for review.