Failure to Update Care Plan with Fall Interventions
Penalty
Summary
The facility failed to update the care plan with specific interventions following two separate falls experienced by a resident with severe cognitive impairment and significant care needs. After falls on two consecutive days, documentation indicated that interventions such as PRN medications, frequent rounding, and hospice review for medication side effects were implemented. However, these interventions were not incorporated into the resident's care plan as required. The most recent care plan revision did not reflect these new interventions, despite documentation and policy indicating that such changes should be made and communicated to staff. Interviews with facility staff, including a nursing assistant, an LPN, and an RN, confirmed that the care plan was the primary source for fall interventions and that the management team was responsible for updating it. The RN acknowledged that the new interventions following the falls should have been added to the care plan but were not. The administrator also confirmed that staff were expected to refer to the care plan for fall interventions and that management was responsible for timely updates. The facility's Post Fall Assessment policy required care plan changes to be made and communicated as appropriate, which did not occur in this instance.