Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident with Alzheimer's disease, dementia with behavioral disturbance, and agitation after the resident experienced two falls. The resident had severely impaired cognition, required a wheelchair for mobility, and needed substantial to total assistance with activities of daily living. Despite being identified as at risk for falls due to poor cognition, incontinence, impaired mobility, and medication use, the care plan was not updated with new interventions following unwitnessed and witnessed falls. After the first fall, which occurred when the resident attempted to replace her shoe without locking the wheelchair brakes, no new interventions were added to the care plan. Similarly, after a second fall in the dining room, where the resident missed the wheelchair while attempting to sit, the care plan remained unchanged. Staff interviews confirmed that the facility's process required assessment and implementation of new interventions after each fall, with subsequent care plan revision. However, documentation and care plan review showed that no new fall prevention strategies were added after either incident. The facility's policy required ongoing updates to the care plan as residents' needs changed, but this was not followed in the resident's case, resulting in a lack of updated interventions after multiple falls.