Failure to Update Care Plan with Progressive Interventions After Multiple Falls
Penalty
Summary
The facility failed to revise and update the care plan with progressive interventions following multiple falls for one resident with a history of repeated falls, hemiplegia, and difficulty walking. The resident required varying levels of assistance for mobility and transfers, as documented in the Minimum Data Set. Despite being identified as high risk for falls due to cognitive and functional deficits, the care plan was not consistently updated with new interventions after each fall event. Multiple nursing notes documented a series of falls experienced by the resident, including incidents where the resident was found on the floor after attempting to use the urinal, transferring to the toilet, or moving from bed to wheelchair. In several instances, no new interventions were added to the care plan following the falls, and in other cases, only minimal interventions such as education or equipment checks were documented. The care plan did not reflect a systematic approach to updating interventions based on the root cause of each fall, as required by facility policy. Facility policy mandates that the care plan be evaluated and modified as needed after each fall, with new interventions based on root cause analysis. However, the record review and staff interview confirmed that this process was not consistently followed for the resident in question. The lack of timely and progressive updates to the care plan after each fall event constituted a deficiency in the facility's fall prevention and management practices.