Failure to Update Care Plans and Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that three residents received adequate supervision and timely, effective interventions to prevent future falls, as required by their own Fall Prevention and Protocol policy. For one resident with Parkinson's Disease, impaired mobility, and visual deficits, a fall occurred while attempting to transfer to bed, and the resident was found with saturated clothing and had reportedly refused care. Despite a high fall risk score and a policy requiring a fall risk evaluation and care plan update after each fall, no such evaluation or care plan revision was completed following the incident. The Director of Nursing confirmed that these steps should have been taken but were not. Similarly, another resident with hemiplegia, aphasia, and a history of multiple falls did not have a fall risk assessment or care plan update after a fall, despite repeated incidents and a policy mandating these actions. A third resident, who required a Hoyer lift and experienced a fall, also did not have any new interventions added to their care plan after the event. In all cases, the Director of Nursing acknowledged that care plans should have been updated after each fall, but this was not done, resulting in a failure to implement effective measures to reduce the likelihood of future accidents.