Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update and implement a comprehensive care plan for a resident following a fall that resulted in injuries. The resident, who was observed sitting in a wheelchair outside his room, reported stumbling and falling in his room while trying to reach his bed, which he described as being too high to sit on. This incident led to the resident sustaining an open wound on his right arm and stitches on his forehead, necessitating a hospital visit. Despite these injuries, the resident's care plan was not updated to reflect new interventions or precautions to prevent future falls. The resident was admitted with multiple diagnoses, including difficulty in walking, and was dependent on staff for all activities of daily living and transfers. A progress note indicated that the resident was found on the floor with injuries, and a Change in Condition (CIC) evaluation was initiated but not completed. The resident's care plan, which included interventions such as using the bed in the lowest position and encouraging the use of a call bell, was not revised after the fall to address the new risks and needs. Interviews with staff revealed that the resident required close supervision due to his condition, which included periods of confusion and unawareness of his surroundings. The facility's policy on managing and preventing falls emphasized the need for a resident-centered prevention plan and updating care plans based on evaluations and current data. However, the facility did not adhere to these guidelines, as evidenced by the lack of timely updates to the resident's care plan following the fall.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident #21 was immediately assessed by a licensed nurse. No concerns were noted. On post-care plan for Resident #21 was updated and intervention was implemented by Director of Nursing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; By , a quality review was completed by Director of Nursing for post-care plan updates and interventions. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , clinical staff were educated on the components of Develop/Implemented a Comprehensive Care Plan with an emphasis on post-care plan updating and intervention in timely manner by the Director of Nursing. Newly hired licensed nurses will be educated on the components of Develop/Implemented a Comprehensive Care Plan with an emphasis on post-care plan updating and intervention in timely manner by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents with post-care plan and intervention 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the facility is within compliance. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.