Failure to Revise Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the fall care plan for a resident following a fall incident. After the resident experienced a fall, a post-fall assessment recommended monitoring the proper wearing of shoes and the use of a front-wheeled walker (FWW) during ambulation. However, the resident's care plan continued to indicate the use of non-skid socks when ambulating with a FWW, rather than updating the intervention to reflect the recommendation for proper shoe use. Observations showed the resident ambulating with shoes and regular socks, and at times with only one shoe and a regular sock, which did not align with the care plan interventions. The resident had a history of cerebral infarction, macular degeneration, generalized muscle weakness, and abnormal gait, and was assessed as moderately cognitively impaired. The resident was receiving restorative services for ambulation and was able to walk with a walker without staff assistance. Interviews with staff, including the DON and LVN, confirmed that the care plan had not been updated to include the new interventions recommended after the fall, such as monitoring the proper use of shoes and ensuring the walker was kept close to the resident during ambulation. The facility's policy required that care plans be resident-centered and updated with new interventions if falls recurred. Despite this, the care plan remained outdated, listing non-skid socks as an intervention rather than the recommended use of shoes. Staff acknowledged the importance of revising the care plan to reflect the resident's current needs and function, but this was not done, resulting in a lack of clear guidance for staff to prevent further falls.