Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans for three residents were updated to reflect their current condition following falls, as required by facility policy and state regulations. Specifically, after each resident experienced a fall, there was no documented evidence that the care plans were revised to include the details of the incident or to add new interventions to address the increased risk or to evaluate the effectiveness of existing interventions. The facility's own policies require care plans to be updated after significant changes in a resident's condition, including falls, and to document any new or modified interventions. One resident with end stage renal disease, atrial fibrillation, and peripheral vascular disease experienced a fall while being transported to hemodialysis. Although the incident was documented in progress notes and an accident report, the resident's care plan was not updated to reflect the fall or any new interventions. Another resident with peripheral vascular disease, anxiety disorder, and a history of cerebrovascular accident had an unwitnessed fall from bed, but the care plan last reviewed several months prior did not include this event or any new interventions. A third resident with chronic obstructive pulmonary disease, iron deficiency anemia, and an aneurysm also experienced an unwitnessed fall out of bed, and while the fall risk score was updated, there was no evidence of new interventions or a revised care plan following the incident. Interviews with facility leadership, including the acting DON, Regional Director of Operations, and Regional Nursing Coordinator, confirmed that care plans were not updated after the falls for these residents. The staff were unable to provide any documentation showing that the care plans reflected the falls or any subsequent changes in interventions, despite facility policy requiring such updates.