Failure to Update Care Plans with Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that care plans for three residents were revised to include fall prevention recommendations made by the Interdisciplinary Team (IDT) following multiple falls. For each resident, the IDT conducted meetings after fall incidents and documented specific recommendations such as keeping the bed in the lowest position, using non-skid socks, providing a clutter-free environment, using floor mats, and implementing bowel and bladder retraining programs. However, these recommendations were not incorporated into the residents' care plans, as confirmed by a review of the care plans and interviews with the Director of Nursing (DON). Resident 1 experienced multiple falls and had IDT recommendations documented after each incident, but these were not reflected in the care plans. Similarly, Resident 2 had several falls and repeated IDT meetings with recommendations, including additional interventions like bolster mattresses and x-rays, none of which were updated in the care plans. Resident 3 also had multiple falls, and the IDT's recommendations were not incorporated into the care plans. In each case, the DON acknowledged during interviews that the care plans had not been updated as required. The facility's policy and procedure on falls required that care plans be updated following a fall and that a post-fall assessment be completed, documenting that the care plan was revised to reflect new interventions. Despite this policy, there was no documentation that the care plans for these residents were updated after their falls, and the DON was unaware of the required post-fall assessment form referenced in the policy.