Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to re-evaluate and update the care plan with new interventions for a resident who experienced multiple falls over several months. Despite repeated incidents, the care plan was not revised to reflect new or different interventions after each fall, as required by facility policy and regulatory standards. The care plan contained duplicate interventions with different dates, and new interventions implemented after falls were not consistently added to the resident's care plan. The resident involved had a complex medical history, including neurocognitive disorder with Lewy bodies, major depressive disorder, dementia, and a history of traumatic brain injury. The resident was identified as being at high risk for falls, with multiple documented falls occurring both from bed and wheelchair, often while attempting self-transfers or sitting on the edge of the bed. After each fall, interventions such as education on call light use, neurological checks, and environmental adjustments were documented in progress notes and fall investigations, but these were not systematically incorporated into the formal care plan. Interviews with the Director of Nursing confirmed that the care plan was not updated after each fall and that there were duplicate interventions listed. The DON acknowledged ongoing challenges with the resident's memory and behavior due to Lewy Body Dementia but could not identify additional measures to prevent further falls. Facility policy required care plans to be revised when the desired outcome was not met or when the resident's condition changed, but this was not followed in the case of this resident.