Failure to Revise and Update Comprehensive Care Plans After Falls
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plans within the required timeframe for two residents who experienced multiple falls, including one with a major injury. For one resident with severe cognitive impairment and a history of 22 falls, the care plan was not updated to reflect each fall or to include new or escalated interventions. Documentation showed that only four of the 22 falls had any interventions recorded, and the majority of falls lacked both interventions and updates to the care plan. Staff interviews confirmed that fall interventions were not consistently included in the care plan used by direct care staff, and some interventions, such as the use of a floor mat, were not maintained or documented in the care plan. For the second resident, after an unwitnessed fall resulting in a major injury and subsequent readmission, the care plan was not revised to address the new risks or to include interventions following the incident. Review of records indicated that several falls occurred without corresponding updates to the care plan, and some incident reports lacked any documented interventions. Staff interviews revealed that care plans had not been generated or updated due to the absence of a Director of Nursing, and the care plans available to staff were incomplete, focusing mainly on basic care needs rather than comprehensive fall prevention or response. Facility policy requires that comprehensive, person-centered care plans be developed within seven days of the comprehensive assessment and updated with any significant change in condition, such as falls. The failure to update care plans after repeated falls and significant injuries, as well as the lack of documented interventions, demonstrates noncompliance with facility policy and regulatory requirements. Staff interviews further confirmed that the care plans in use did not reflect current risks or interventions, and there was a lack of leadership oversight to ensure care plans were maintained and revised as needed.