Failure to Update Care Plan for Recurrent Falls
Penalty
Summary
The facility failed to update a resident's care plan to include specific interventions to prevent a recurring pattern of falls, despite multiple documented incidents. The resident experienced several falls, most of which occurred between 3:00 a.m. and 5:00 a.m. while attempting to go to the bathroom independently. These falls resulted in injuries, including a laceration, skin tear, abrasion, and ultimately a hip fracture that required surgical intervention. The care plan was revised after some of these incidents, but did not include targeted interventions such as scheduled checks during the high-risk time frame. Progress notes and interviews revealed that both staff and the resident's power of attorney (POA) recognized the pattern of falls occurring during early morning hours. The POA specifically requested that staff check on the resident during these times to help prevent further incidents. An LPN confirmed having this conversation with the POA but did not communicate the request to the night shift or management, and the intervention was not added to the care plan. The Director of Nursing (DON) acknowledged that information about the resident's fall pattern and the POA's request should have been communicated to management and incorporated into the care plan. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, but this was not followed in the case of this resident, resulting in a lack of appropriate interventions to address the identified risk.