Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and updated in a timely manner following a fall, leading to a deficiency. Resident #164, who was admitted with a high risk for falls due to multiple diagnoses including balance problems and decreased muscular coordination, experienced a fall on 12/2/24. Despite a medical assessment on 11/29/24 that highlighted the resident's deficits in mobility and activities of daily living, and the high risk of falls, the care plan was not revised to include new interventions after the fall. The resident was sent to the hospital for examination, but no fractures were found. Subsequently, the resident experienced another unwitnessed fall on 12/08/24, resulting in a head laceration and bruises on both knees, necessitating another hospital visit. Interviews with the Director of Nursing and a Licensed Practical Nurse revealed that the care plan should have been reviewed and updated with new interventions after the initial fall, but this was not done. The failure to update the care plan after the fall on 12/2/24 was a key factor in the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 P(NAME) F657 I. Immediate Corrective Action: 1) Resident #164 is no longer in the facility and was discharged with no outward or obvious issues. II. Identification of Others: 1) All residents could potentially be affected. 2) A list of residents who are potential for fall risk will be generated from the medical record. The comprehensive care plan was reviewed to ensure that all residents who are at risk were updated to reflect current status and contained new interventions to enhance communication. Any identified issues were addressed. 3) All residents who have had falls in the past 30 days will have their CCP’s reviewed and updated to include any necessary safety, supervision, and resident-specific precautions and interventions. 4) Education was provided to all RN’s tasked with updating Care Plans with respect to updating the plan of care for residents every time there is a fall; specifically that a new intervention must be in place post each fall and/or after a change in condition. III. Systemic Changes: 1) The DNS and Administrator reviewed the Policy and Procedure for CCP and found same to be in compliance. 2) All Registered Nurses responsible for care planning will receive Inservice Education given by the Inservice Educator/DON/ADON on updating the CCP with quarterly MDS assessments and when any episodic event happens including falls, other incidents, or change in conditions. Highlights of the lesson plan include: - The care planning process to include Assessment Planning, Goals/Interventions, Monitoring/Evaluation. - The responsibility of the RNs to review the CCP after each MDS assessment, fall, incident, and/or change in condition and revise, based on changing goals, preferences, needs of the resident. - The responsibility of the RNs to revise and update the plan of care when an episodic event occurs. IV. Quality Assurance: 1) The DNS developed an audit tool to monitor the facility’s compliance with updating the Fall CCP with interventions after each fall any resident experiences. 2) All residents that have had falls or change in conditions within the last 30 days or who are on the list of “potential to fall” will be reviewed by the DON/ADNS to ensure that the CCP has been updated to reflect any new interventions if need be. This audit will start as weekly x 4 weeks and monthly x 11 months. 3) Any findings that require interventions will be addressed immediately and discussed in the next QA. V. Person Responsible for F Tag: DNS