Failure to Update Care Plans and Complete Fall Risk Evaluations After Resident Falls
Penalty
Summary
The facility failed to implement and/or revise individualized care plans and complete fall risk evaluations for three out of five residents reviewed for accident hazards and supervision. One resident experienced multiple unwitnessed falls over a period of time, including incidents resulting in a hematoma, yet the care plan was not updated with new interventions after several of these falls. The resident's records indicated significant physical impairments, including lower extremity impairment, wheelchair use, and dependence on staff for transfers and toileting, but interventions remained largely unchanged despite repeated incidents. Another resident, with diagnoses including chronic obstructive pulmonary disease and mental health disorders, was identified as at risk for falls in prior evaluations but did not have a current care plan reflecting this risk. After a witnessed fall and an episode of unsteady gait possibly related to alcohol consumption, no new fall risk evaluation was completed. The resident reported frequent outdoor walks and described a recent incident where she tripped outside the facility, but there was no evidence of updated assessment or intervention following this event. A third resident, who was moderately cognitively impaired and required assistance with mobility, was documented as a high fall risk in a previous evaluation, but her care plan did not reflect this status. Family members and staff interviews confirmed that this resident had experienced falls both inside and outside the facility, with at least one incident observed by a family member and reported to emergency services. Staff acknowledged that fall risk care plans and evaluations should be updated after falls, but this was not consistently done. The facility's own policy required post-fall evaluations and care plan updates, which were not followed in these cases.