Failure to Update Care Plan and Supervise High-Risk Resident Leads to Multiple Falls
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and update the plan of care for a resident with severely impaired cognition and a high risk for falls. The resident experienced multiple falls, including one resulting in major injury with bilateral hip fractures. Despite repeated incidents, the care plan was not consistently updated with new interventions, and the recommended interventions were not always implemented or reviewed for effectiveness. For example, after an initial fall, the intervention to have the resident sit in a recliner in the lobby was not put into practice, and the resident continued to fall from the wheelchair in the lobby multiple times. The resident's clinical record showed a history of dementia with agitation, unsteadiness, and muscle weakness, requiring varying levels of assistance for mobility and daily activities. The resident had a pattern of restlessness and attempts to stand or pick up objects, leading to falls, most of which occurred while seated in a wheelchair in the lobby. The care plan included several interventions over time, such as anti-roll back devices, brake extenders, and reminders to use assistive devices, but these were not always updated or implemented after each fall as required by facility policy. Additionally, the use of a Broda chair, which was observed during the survey, was not included in the care plan. Documentation and follow-up after falls were inconsistent. Interdisciplinary Team (IDT) meetings and root cause analyses were not conducted after every fall, and new interventions were not always introduced. Neurological checks following unwitnessed falls were not completed according to policy, and care plan meetings did not always address changes in the resident's behavior or condition. These lapses in supervision, care planning, and documentation contributed to repeated falls and injuries for the resident.