Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan and interventions for a resident after the resident experienced an unwitnessed fall. The resident, who had diagnoses including parkinsonism, schizoaffective disorder, and major depressive disorder, was assessed as having moderately impaired cognitive skills and was dependent on staff for activities of daily living. Following the fall, the Interdisciplinary Team (IDT) met and recommended new interventions, such as the use of bed rails for safe bed mobility, but these interventions were not incorporated into the resident's care plan. Interviews with facility staff, including the MDS nurse, QA nurse, and DON, confirmed that although a short-term care plan was developed and the IDT recommended additional interventions, the long-term care plan was not updated to reflect these changes. The facility's policy required the care plan to be reviewed and updated after significant events such as falls, but this was not done in this case, resulting in a failure to communicate new interventions to staff responsible for the resident's care.