Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to revise and update care plans related to falls for four residents, as required by their own policy and federal regulations. The policy states that care plans must be reviewed and updated when there is a significant change in a resident's condition, when desired outcomes are not met, or at least quarterly. However, for several residents with a history of falls and high fall risk, care plans were not updated to reflect new fall incidents or changes in interventions. One resident was re-admitted with a history of stroke and repeated falls, and experienced multiple falls, including one that resulted in shoulder pain. Despite these incidents, the care plan was not updated to include the most recent fall. Another resident with cerebrovascular disease and impaired cognition had multiple falls, including one with injury, but the care plan did not document these events or address them with new interventions. The Director of Nursing confirmed that care plans should have been updated as falls occurred. A third resident with vascular dementia and moderate cognitive impairment had two non-injury falls during the assessment period. Although the resident was placed in a Geri chair as a new intervention to address fall risk, this change was not reflected in the care plan for over 30 days. Staff interviews confirmed that the Geri chair was a therapy intervention and should have been included in the care plan, but it was not. These omissions demonstrate a failure to ensure care plans were current and reflective of residents' needs and conditions.