Failure to Update Care Plan After Unassisted Transfer Attempts in High Fall Risk Resident
Penalty
Summary
The facility failed to revise the care plan for a resident at high risk for falls after the resident experienced episodes of attempting to get up unassisted. The resident, who had a history of falling, a right femur fracture, dementia, osteoarthritis, abnormal gait, and generalized muscle weakness, was admitted with significant mobility and cognitive impairments. The Minimum Data Set assessment indicated the resident required varying levels of assistance for daily activities and had not attempted transfers or walking due to safety concerns. Despite these risks and a documented fall prior to admission, the care plan, which included interventions such as call light accessibility, low bed, floor mats, and pressure pad alarms, was not updated after the resident attempted to get up unassisted from a wheelchair on two occasions. Interviews with facility staff confirmed that the care plan had not been revised following these incidents to include additional interventions, such as more frequent monitoring. The facility's policy required individualized care plans for residents at high risk for falls, with updates as new issues arose. However, the lack of timely care plan revision after the resident's unassisted transfer attempts represented a failure to address the resident's changing needs and risk factors as required by facility policy and regulatory standards.