Failure to Update Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for two residents who experienced falls. According to facility policy, care plans are to be updated as residents' conditions change, and each fall should prompt a follow-up and the addition of new interventions to the care plan. For one resident, who was assessed as severely cognitively impaired and had a documented fall where they lowered themselves to the floor due to weakness, staff did not add a new intervention to the care plan after the incident. The MDS Coordinator and DON both acknowledged that the event qualified as a fall and that a new intervention should have been added, but it was overlooked. For another resident, assessed as moderately cognitively impaired, staff also failed to document a new intervention in the care plan after the resident slid off the bed onto their buttocks. The MDS Coordinator was unaware of the fall and therefore did not implement a new intervention, while the DON admitted to overlooking the addition of a new intervention. Interviews confirmed that the IDT discusses new interventions after each fall and that the MDS Coordinator is responsible for updating care plans, but in these cases, the required updates were not made.