Failure to Update Care Plan After Fall and Therapy Recommendation
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a comprehensive care plan was reviewed and revised to reflect a resident's current condition following a fall. The resident, who had diagnoses including Alzheimer's disease, dependence on renal dialysis, and a history of falls, experienced a fall from their wheelchair. After the incident, an occupational therapy assessment recommended that an additional mechanical lift pad, used during outside appointments such as dialysis, should be removed immediately upon the resident's return to reduce the risk of sliding forward and falling again. This recommendation was communicated to the nursing staff and the unit manager nurse. Despite the occupational therapist's recommendation and the facility's policy requiring care plans to be updated after a fall investigation, there was no documented evidence that the care plan was revised to include the new safety intervention. Both the occupational therapist and the unit manager nurse confirmed during interviews that the care plan did not reflect the recommended intervention, and the unit manager acknowledged responsibility for updating the care plan but had not done so.