Care Plan Not Updated After Fall Incident
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect current needs and interventions following a fall incident. Specifically, after a resident with multiple diagnoses, including acute osteomyelitis and adult failure to thrive, experienced a fall while leaning forward in a wheelchair to reach food and drink, the interdisciplinary team (IDT) assessed the situation and recommended that staff ensure the resident's food and drink be placed closer to him in the dining room. However, this recommendation was not incorporated into the resident's care plan fall prevention interventions. Record review, policy review, and staff interview confirmed that the care plan was not updated to include the IDT's recommendations after the fall. The facility's policy required that a person-centered plan of care be developed and revised by the interdisciplinary team to address falls and prevent future occurrences. The Director of Nursing acknowledged that the care plan had not been updated as required.