Failure to Update Care Plan with Resident-Specific Fall Prevention Interventions
Penalty
Summary
The facility failed to update and individualize the care plan with resident-specific fall prevention interventions for a resident who experienced multiple falls. The resident, who was cognitively intact and had diagnoses including osteomyelitis, chronic respiratory failure, congestive heart failure, diabetes type II, repeated falls, muscle weakness, and unsteadiness, had a care plan that was not consistently revised after each fall event. Although the care plan was updated to change the transfer assistance level after a fall that resulted in a clavicle fracture, there was no evidence that additional or modified fall prevention interventions were implemented following five subsequent falls. Event reports and nursing notes documented multiple unwitnessed and witnessed falls, many of which occurred during self-transfers in the resident's room or bathroom. Interviews with the resident revealed that they often transferred themselves between bed, wheelchair, and recliner, and sometimes did not use the call light or non-skid footwear. Staff interviews indicated inconsistent understanding and communication regarding the resident's transfer status and the need for assistance, with some staff believing the resident was independent and others acknowledging the need for standby or one-person assist. The care plan did not reflect interventions such as increased rounding, toileting assistance, or environmental modifications that were discussed or implemented informally by staff. The facility's policies required that fall risk and appropriate interventions be included in the care plan and updated after each fall review. However, both the RN and DON confirmed that while some interventions were carried out, they were not documented in the care plan. The care plan also did not address the resident's self-transfer behaviors under the behavior section, despite repeated incidents. This lack of comprehensive and updated documentation in the care plan contributed to the deficiency identified by surveyors.