Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident after each fall, as required by policy and procedure. The resident, who had a history of falls, was admitted with diagnoses including type 2 diabetes mellitus, muscle weakness, unsteady gait, and abnormal mobility. Upon admission, the resident was assessed as high risk for falls, and a care plan was developed with interventions such as anticipating needs, ensuring the call light was within reach, promoting physical activity, and using non-skid socks. The resident was cognitively intact and required assistance with activities of daily living. Despite these interventions, the resident experienced two unwitnessed falls on consecutive days. The first fall resulted in the resident being found on the floor next to her bed, with no injuries reported. The second fall occurred the following day, resulting in significant injuries, including a fractured rib and bruising, and required transfer to the emergency room. Occupational therapy noted increased confusion and impaired safety awareness after the second fall, recommending that the resident use a wheelchair and call for staff assistance for all transfers. Interviews with staff confirmed that interventions such as frequent monitoring and education on using the call light were initiated after the falls. However, these new interventions were not documented or updated in the resident's care plan. The Director of Nursing acknowledged that the care plan was not revised after the falls, contrary to facility policy, which requires care plans to be updated as residents' conditions change. Review of facility policies confirmed that each fall should be followed by an update to the plan of care with new interventions.