Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised in response to ongoing falls and changes in condition. The resident, who was re-admitted with multiple complex diagnoses including Parkinson's disease, dementia, traumatic brain injury, and a history of falls, experienced repeated falls and behavioral issues over a period of several weeks. Despite multiple documented incidents of falls, changes in mental status, and recommendations for increased supervision and interventions, the care plan was not updated to reflect these events between February 9 and March 4. Documentation shows that the resident was highly confused, unable to use the call light, and exhibited behaviors such as wandering, attempting to self-transfer, and removing medical devices. The resident had several falls, some resulting in injury or requiring hospital evaluation, and staff implemented various interventions such as 1:1 supervision, use of a wander guard, and environmental modifications. However, these interventions and the resident's changing needs were not consistently reflected in the care plan during the identified period. Interviews with staff confirmed that the expectation was to update the care plan after each fall or significant change, and the Director of Nursing acknowledged that the care plan lacked necessary updates during the period of repeated falls. Review of facility policy also indicated that care plans should be revised as residents' conditions change, but this was not done for the resident in question, resulting in a deficiency related to care planning and resident safety.