Failure to Update Care Plan and Conduct Interdisciplinary Review After Resident Falls
Penalty
Summary
The facility failed to ensure that professional standards were followed regarding care planning and interdisciplinary review after falls involving a resident with severe cognitive impairment, encephalopathy, aphasia, and depression. The resident required partial to moderate assistance for transfers and was identified as being at risk for falls due to a history of falls and cognitive impairment. Despite documented falls on two separate occasions, there was no evidence in the clinical record that the care plan was updated or that an interdisciplinary team meeting was conducted to review the incidents, as required by facility policy. Nursing notes indicated that after each fall, assessments were performed, vital signs were checked, and the resident's family and providers were notified. However, interviews with staff and review of the clinical record confirmed that the care plan was not revised to address the falls, and there was no documentation of an interdisciplinary review. The facility's Fall Management System policy requires that the care plan be updated to address factors contributing to falls, but this was not done for the resident in question.