Failure to Update Care Plan with New Fall Intervention
Penalty
Summary
A deficiency occurred when the facility failed to update a resident's care plan with a new fall intervention identified by the Interdisciplinary Team (IDT) after the resident experienced an unwitnessed fall. The resident, who was sitting in a chair in the dining room, attempted to scoot forward and slid out of the chair, landing on her buttocks. The IDT reviewed the incident and suggested a new intervention: redirecting the resident to sit on a couch instead of a chair, as she was able to get up from the couch without difficulty. This intervention was documented in the IDT event review note but was not added to the resident's care plan. As a result, the direct care staff did not have access to the updated intervention, which was necessary to address the specific circumstances of the resident's fall. The facility's policy requires that care plans be revised as information about residents and their conditions change, and that the IDT must review and update care plans when there is a significant change in condition or when desired outcomes are not met. Despite these requirements, the new intervention was not incorporated into the care plan, leading to a deficiency in care planning and communication.