Failure to Update Fall Interventions and Care Plans After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls received proper assessments and interventions to prevent further accidents. The resident, who had severe cognitive impairment and required substantial assistance for mobility, experienced multiple falls within a short period. Despite documented incidents, including unwitnessed falls resulting in significant injuries such as fractures to both arms, the facility did not update the resident's care plan or implement new interventions after each event. The care plan remained unchanged even after the resident returned from the hospital with a cast, which the resident repeatedly removed, leading to additional falls and injuries. Staff interviews revealed that after each fall, assessments and incident reports were completed, but immediate interventions were not consistently documented or added to the care plan. The process for updating care plans and communicating new interventions to staff was not followed, particularly in the absence of a Director of Nursing (DON). The Assistant Director of Nursing (ADON) acknowledged that fall assessments and care plan updates were not being completed due to the lack of a DON, and that there was confusion among staff regarding their responsibilities in monitoring and preventing falls. The facility's policy required staff to identify and implement pertinent interventions after each fall, but this was not adhered to. The lack of timely and appropriate interventions, failure to update care plans, and insufficient staff training and oversight contributed to repeated falls and serious injuries for the resident. These actions and omissions resulted in non-compliance with federal requirements for quality of care and accident prevention.
Removal Plan
- Fall assessments and interventions reviewed and updated as needed for Residents #15 and #25 by facility nurse.
- In-service by administrator, regional director and nurse consultant for Nursing staff (RN, LPN, CNA) present and via phone for those not in facility regarding the following: Assessing, monitoring and intervening in falls to prevent injury and/or reduce falls; Proper interventions for falls; Care plans related to falls; Notification of PCP, DON, family and administrator.
- DON/Administrator in-serviced by regional director in regards to monitoring of incident and accident (I&A), fall records and daily nurse documentation to identify and address any concerns immediately.