Failure to Timely Update Fall Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to ensure that care plans for three residents at high risk for falls were reviewed, revised, or updated in a timely manner following fall incidents, as required by facility policy. For one resident with severe cognitive impairment and multiple diagnoses, including chronic pain syndrome and dementia, the care plan was not updated after two falls, one of which resulted in significant injuries including a femur fracture and scalp laceration. Although staff reportedly implemented new interventions such as placing a fall mat and lowering the bed, these changes were not documented in the resident's care plan. Another resident, also with severe cognitive impairment and a history of falls, experienced multiple falls over several months. The care plan interventions were not consistently updated after each fall. In some cases, interventions were added to the care plan days or weeks after the fall occurred, and in other cases, interventions were already listed in the care plan prior to the fall, indicating a lack of timely review and revision. Documentation did not always reflect the implementation of new or different interventions following each incident. A third resident with dementia and a history of falls also had multiple falls, with care plan interventions not being updated promptly. For some falls, interventions were documented as being added to the care plan weeks after the incident, and in other cases, no new interventions were documented at all. Interviews with facility staff, including the DON and LPN, confirmed that changes to care plans should be documented at the time interventions are implemented, but this was not consistently done for these residents.