Failure to Update Care Plan with Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to review and update the care plan for a resident with a history of falls and severe cognitive impairment. The resident, an elderly female with diagnoses including dementia, diabetes, hypertension, and a history of fractures, experienced multiple falls during her stay. Despite these incidents, the care plan was not revised to include appropriate safety interventions such as fall mats or a low bed, even after unwitnessed and witnessed falls occurred on several occasions. Clinical records and progress notes indicated that the resident had at least three falls, including one resulting in a hip fracture and others without injury. Observations over several days confirmed that the resident's room did not have fall mats and the bed was not kept in a low position. Staff interviews revealed that interventions prior to the most recent fall were limited to encouraging call light use and keeping the call light within reach, despite the resident's severe cognitive impairment and inability to use the call light appropriately. Physical therapy assessments noted the resident's high fall risk and difficulty with transfers but did not recommend specific fall precautions. The facility's care planning policy requires that care plans remain current and address residents' needs, but the care plan for this resident was not updated with effective fall prevention interventions after repeated falls, as confirmed by staff and record review.