Failure to Revise Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was revised to address the ongoing care needs of a resident with a history of repeated falls. The resident, who had diagnoses including repeated falls, diabetes, left hip pain, bipolar disorder, and dementia, experienced eight falls over a six-month period. Despite multiple incidents, including falls in the bathroom and bedroom, care plan interventions were either not updated or only minimally addressed, such as ensuring toileting after meals or applying anti-rollback bars to the wheelchair. Several falls resulted in injuries, including a 3 cm abrasion above the left eyebrow and a laceration with a knot, yet no new care plan interventions were implemented following these events. Interviews with staff revealed that the resident often attempted to self-transfer, leading to falls, and that while incidents were discussed in daily meetings, these discussions did not result in updates to the care plan. The care plan was not consistently revised to reflect the resident's changing needs or to implement new interventions after each fall. Documentation showed that recommendations, such as transferring the resident to the unit dayroom with nursing staff, were discussed but not added to the care plan or put into practice. This lack of timely and comprehensive care plan revision resulted in the potential for additional falls and unmet care needs.