Failure to Update Care Plans for Safety and Fall Interventions
Penalty
Summary
The facility failed to update and revise care plans related to safety and fall interventions for two residents. For one resident with a history of dementia, mood disturbance, and self-harm, the call light cord had previously been removed after an incident where the resident attempted self-harm using the cord. The care plan was updated to provide a hand bell instead. However, following a care plan meeting with the resident's family, the call light was returned to the room and zip-tied to the bed rail, but the care plan was not updated to reflect this change. The DON confirmed that the care plan should have been revised to document the new intervention. For another resident with cognitive impairment and a history of falls, the care plan indicated that roll back brakes were added to the wheelchair as a fall prevention measure. However, observations showed that anti-lock brakes were no longer present on the wheelchair, and the DON stated that this intervention was outdated and should have been discontinued in the care plan. The failure to update the care plans resulted in discrepancies between the residents' current interventions and what was documented.