Failure to Revise Care Plan with Fall Prevention Interventions
Penalty
Summary
The facility failed to revise the care plan to include safety interventions for a resident who was at high risk for falls and had already sustained two falls within the facility. The resident had significant medical conditions, including abnormalities of gait and mobility, lack of coordination, and a contracture of the right forearm, and was determined to lack the capacity to make medical decisions. The Minimum Data Set indicated the resident required partial to moderate assistance with activities of daily living and needed supervision or assistance with transfers and walking. Despite these needs and two documented falls—one witnessed and one unwitnessed—resulting in injuries such as abrasions, swelling, and a laceration, the care plan was not updated to include specific safety measures to prevent further falls. Interviews with nursing staff confirmed that the care plan did not reflect necessary safety interventions following the resident's falls. The facility's policies required that care plans be updated after every fall and upon changes in condition, but this was not done for the resident in question. The lack of timely revision and inclusion of fall prevention interventions in the care plan was identified as a deficiency, as it did not provide adequate guidance for staff to address the resident's increased risk of falls.