Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of repeated falls following a new fall incident. The resident, who had diagnoses including schizophrenia, bipolar disorder, and overactive bladder, was identified as having moderate cognitive impairment and required one-person assistance with ambulation and toileting. The care plan in place noted the resident's risk for falls due to an unsteady gait and noncompliance with seeking assistance, with interventions such as ambulation with a walker and not leaving the resident unattended. Despite a physician's order specifying the use of a two-wheeled rolling walker for transfers and ambulation, the resident experienced a fall after being left unattended in their room. Following the fall, documentation showed that the resident was last assisted with toileting and later found on the floor after attempting to walk to the bathroom alone. The post-accident report and care plan review revealed that the care plan was not updated after the incident to address the new fall and prevent future occurrences. The Director of Nursing Services (DNS) acknowledged that the care plan had not been revised, citing a lack of additional interventions to implement. This failure to update the care plan was not in accordance with the facility's fall prevention policy, which requires evaluation and implementation of measures to prevent falls for at-risk residents.