Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident after 10 incidents of unwitnessed falls, despite the resident being identified as high risk for falls. The resident, who was admitted with diagnoses including Peripheral Vascular Disease, pain in the left leg, cognitive communication deficit, and generalized anxiety disorder, had a history of moderate to advanced dementia and required total care. The care plan for falls was initiated, and interventions such as floor mats and a private caregiver during the day were in place. However, the care plan did not reflect input from the resident's representative, and there was no evidence that the plan was updated or revised after repeated falls, as required by facility policy and procedure. Observations and interviews revealed that staff were aware of the resident's frequent falls, particularly at night, and that the resident exhibited anxiety and confusion. The facility's fall risk assessments consistently indicated a high risk, and the resident's cognitive assessment was incomplete, with no BIMS summary score documented. Despite these findings and the facility's policy requiring the interdisciplinary team to update the care plan after falls, the care plan remained unchanged after multiple incidents, and the required comprehensive assessment and team review were not documented.