Failure to Timely Update Care Plan After Repeated Wheelchair-Related Falls
Penalty
Summary
Facility staff failed to update a resident's care plan to address repeated falls involving the use of a wheelchair with a broken brake lever. The resident, identified as high fall risk due to balance issues and a history of falls, experienced multiple falls over several months, some of which were directly related to the malfunctioning wheelchair and noncompliance with locking the wheelchair brake. Documentation showed that the resident reported the broken brake lever and that falls occurred when the wheelchair brake was not engaged, resulting in the wheelchair moving unexpectedly during transfers. Despite these incidents, the resident's care plan was not revised to address the specific risks associated with the wheelchair and the resident's compliance with brake usage until several months after the initial falls. The Director of Nursing acknowledged that the resident should have had a behavioral care plan addressing noncompliance with locking the wheelchair brakes but could not explain why the care plan was not updated following earlier falls. The lack of timely care plan revision contributed to the ongoing risk of falls for the resident.