Failure to Revise Care Plan After Fall and Change in Elopement Risk
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident following a fall and a change in elopement risk status. The resident, who had multiple diagnoses including parkinsonism, dementia with behavioral disturbances, and a history of traumatic brain injury, was assessed as having severely impaired cognition and had experienced a fall with injury. Despite documentation in the medical record indicating the resident was no longer at risk for elopement and had sustained a significant fall resulting in head and elbow injuries, the care plan was not updated to reflect these changes. The care plan continued to list the resident as at risk for wandering and elopement, and no new interventions were added after the fall, even though the resident was moved closer to the nurses' station for observation. Review of facility documentation and interviews revealed that the interdisciplinary team did not meet to review or revise the fall risk care plan after the incident, and the MDS Coordinator had not updated the care plan due to not being aware of the latest assessments. The facility's own policies required that care plans be updated immediately after a fall investigation and that new interventions be communicated to staff, but these steps were not followed. Additionally, the fall investigation documentation lacked post-fall follow-up information and did not include newly added interventions.