Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan to include appropriate interventions for falls for a resident with a significant history of falls and multiple complex medical conditions. The resident's diagnoses included overactive bladder, psychotic disorder, substance dependence, delusional disorders, major depressive disorder, epilepsy, mood affective disorder, anxiety, hypertension, lack of coordination, muscle weakness, repeated falls, cognitive communication deficit, reduced mobility, flaccid hemiplegia, pain, and vascular dementia. The resident had severely impaired cognition, required substantial to maximum assistance with activities of daily living, and was frequently incontinent. The Minimum Data Set documented that the resident had experienced a fall with injury. Despite multiple documented falls, including incidents where the resident was found on the floor in his room, sometimes unable to recall the event or how he ended up on the floor, the care plan was not consistently updated to include new interventions after each fall. In several instances, the event notes specifically stated that the care plan lacked an intervention for the fall. Only after one fall was an intervention (placement of nonskid strips) documented, but subsequent falls did not result in additional care plan updates. Staff interviews revealed that nurses were expected to add interventions to the care plan after each fall, and that interventions were communicated during staff huddles. However, a CNA reported not having access to the care plan and relied on nurses for special instructions. The facility's policy required an individualized, comprehensive, person-centered care plan with measurable objectives and time frames to address each resident's needs. However, the care plan for this resident did not reflect timely or consistent updates following each fall event, as required by policy. This lack of care plan revision following repeated falls constituted a deficiency in the facility's care planning process.