Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the care plan for a resident who was at risk for falls, as required following significant changes in the resident's condition and incidents. The resident, who had diagnoses including chronic pain, anxiety, and depression, experienced two falls. The first fall occurred during a transfer from bed to wheelchair when a staff member did not use a gait belt, resulting in the resident falling onto her right knee. The root cause was identified as the lack of gait belt use, and the staff member involved was counseled on proper transfer technique. The second fall happened when the resident attempted to toilet herself and was found on the bathroom floor. After this incident, a new intervention to keep the resident's bed in the lowest position was identified as necessary. Despite these incidents and the identification of new interventions, the resident's care plan was not updated to include the use of a gait belt during transfers or the intervention to keep the bed in the lowest position. The existing care plan only included general fall prevention measures such as keeping the call light within reach, encouraging the use of assistive devices, and monitoring for changes in gait. The Director of Nursing confirmed that the care plan should have been updated with the new interventions following the falls, in accordance with the facility's policy requiring care plan revisions as changes in the resident's condition dictate.