Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update and individualize the care plan for a resident who was at risk for falls, despite multiple incidents of falling. The resident, who had severe cognitive impairment and a history of falls, experienced two falls within a short period. The care plan in place included general fall prevention interventions such as participation in a fall prevention program, reminders to call for assistance, keeping the call light within reach, and supervision. However, after the resident's falls, there was no evidence that the care plan was reviewed or revised to include additional or different interventions tailored to the resident's specific behaviors and needs. Documentation in the medical record and interdisciplinary team (IDT) notes did not address the resident's repeated attempts to transfer without assistance or the falls that occurred. The facility's policy required staff to implement new or different interventions if falls recurred, but this was not done. During interviews, facility leadership confirmed that the care plan was not updated following the falls, and no new interventions were implemented to address the resident's ongoing fall risk.