Failure to Update Care Plan Interventions After Resident Falls
Penalty
Summary
The facility failed to update and revise care plan interventions for a resident with a history of repeated falls. The resident, who had diagnoses including repeated falls and a history of cerebrovascular accident, muscle weakness, seizures, encephalopathy, impaired safety awareness, fatigue, use of antipsychotic medications, and prior falls, reported having fallen out of bed multiple times while attempting to reach for items or self-transfer. Despite these recent falls, the care plan interventions were not updated to reflect the resident's current status or to address additional preventative measures. The care plan had last been revised the day before the interview, but did not include new interventions based on the resident's recent fall history. During an interview, the DON acknowledged that the care plan interventions for falls should have been updated and revised to reflect the resident's current needs. The DON attributed the lack of timely care plan updates to recent staff changes, which made it difficult to ensure care plans were individualized and current. Review of facility policy and regulatory guidance confirmed that care plans must be reviewed and revised after each assessment and in response to changes in the resident's condition, goals, or needs.