Failure to Revise Care Plans with Fall Prevention Interventions
Penalty
Summary
The facility failed to revise and update care plans with appropriate fall prevention interventions for two residents, despite multiple documented falls and near-miss incidents. For one resident with severe cognitive impairment, Alzheimer's disease, and a history of falls, there were repeated unwitnessed falls, some resulting in injury, such as lacerations and hematomas. Despite these incidents, new interventions identified during fall investigations, such as scheduled toileting and not leaving the resident unattended in the bathroom, were not promptly added to the care plan. Additionally, the facility did not provide a fall investigation for at least one unwitnessed fall, and there was confusion among staff regarding responsibility for updating care plans, as reported by both licensed nurses and administrative staff. Another resident, who was dependent on staff for transfers and toileting and had multiple comorbidities including chronic ulcers, diabetes, and morbid obesity, also experienced falls and near-miss events. After a near-miss where the resident nearly slid off the bed and a subsequent fall from bed witnessed by family via camera, interventions such as not waking the resident early and checking on her safety were not immediately incorporated into the care plan. Furthermore, after a fall from a mechanical lift, the intervention to check orthostatic blood pressure was not documented in the care plan, and staff were unaware of any new interventions related to the incident. The facility's own Fall Management and Prevention policy required that individual fall prevention interventions be developed and included in each resident's care plan. However, the care plans for both residents were not updated in a timely manner to reflect new interventions following falls or near-miss events. This lack of timely care plan revision resulted in uncommunicated care needs and placed the residents at risk for further injury.