Failure to Revise and Implement Fall Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise and implement a resident's care plan following a witnessed fall. According to the facility's Accidents/Incidents Policy, the charge nurse or nursing supervisor is required to initiate a care plan change to ensure the resident's welfare and safety before the end of the shift. However, after a resident with a history of falls experienced a witnessed fall with no injury, the care plan was not updated with new goals or interventions. Both the Director of Nursing and the MDS Nurse confirmed that the care plan was not revised as required after the incident. Additionally, the facility did not ensure that existing fall care plan interventions were implemented. The resident's Activities of Daily Living care plan specified the need for maximal assistance and required two staff members for transfers. Despite this, a CNA attempted to transfer the resident alone, resulting in another witnessed fall. The Director of Nursing confirmed that the care plan, which required two staff for transfers, was not followed during this incident.