Failure to Update and Implement Comprehensive Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan with appropriate interventions to prevent falls or reduce the likelihood of injury for a resident with a history of multiple falls. The resident, who had severe cognitive impairment, osteoarthritis, weakness, and mixed incontinence, was identified as being at high risk for falls. Despite having 23 documented falls over a six-month period, the care plan was not updated after each incident and contained limited interventions. Observations revealed that the resident's call light was frequently out of reach, wheelchair brakes were unlocked, and the resident was left unsupervised while attempting to reach for objects, all of which increased the risk of falls. Interviews with CNAs indicated a lack of awareness regarding specific fall interventions for the resident, and staff were unable to identify or locate the interventions in the care plan. The DON confirmed that the care plan had not been updated as required and acknowledged the importance of keeping care plans current to ensure resident safety. Facility policy required care plans to be updated quarterly and as needed, reflecting close evaluation of problems, goals, and approaches, but this was not followed in the resident's case.