Failure to Update Care Plans and Conduct Thorough Fall Investigations
Penalty
Summary
The facility failed to ensure individualized care plan interventions were developed, updated, and implemented following falls for multiple residents, and did not conduct thorough post-fall investigations with root cause analysis. For one resident with a history of falls and moderate cognitive impairment, repeated falls occurred, including incidents resulting in wrist fractures, without evidence of new fall prevention interventions being added to the care plan or thorough investigations being completed. Staff interviews confirmed that witness statements were not consistently obtained, and care plans were not updated after each fall, despite the resident being identified as high risk for falls and requiring assistance with ambulation and toileting. Another resident with hemiplegia, diabetes, and mild cognitive impairment experienced multiple falls over the course of a year. The care plan and fall interventions were not consistently updated to reflect new interventions identified after each fall, and some interventions were delayed in being added to the care plan. Fall investigations lacked witness statements, and immediate interventions were not always documented or incorporated into the resident's care plan in a timely manner. Staff interviews confirmed that fall investigations were often verbal and not thoroughly documented. A third resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a head injury. The post-fall assessment did not identify a root cause, and there were no witness statements or comprehensive investigation documented. The facility's policy required individualized interventions and thorough investigation after each fall, but these procedures were not consistently followed for the residents reviewed.