Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise the care plan to include a new intervention following a resident's fall. The resident, who had diagnoses including dementia with agitation, a history of falling, and anxiety disorder, experienced an unwitnessed fall after being assisted to bed. The clinical record showed that the resident had severely impaired cognition, required moderate assistance for transfers and ambulation, and was at high risk for falls as identified by a recent Fall Risk Evaluation. Despite these risk factors and the occurrence of a new fall, the Accident and Investigation documentation and the Resident Care Plan did not reflect the addition of any new interventions after the incident. Interviews with facility staff revealed that no new interventions were added to the care plan following the fall, and the responsible LPN was unaware that an intervention needed to be added for falls without injury. The Director of Nursing Services confirmed that an appropriate intervention should have been added to the care plan after the fall, and that the RN supervisor was responsible for ensuring the Accident and Investigation was fully completed. The facility's policy directed staff to implement additional or different interventions if falls recurred, but this was not followed in this case.