Failure to Timely Update Fall Prevention Interventions in Care Plan
Penalty
Summary
The facility failed to ensure that new interventions to prevent falls were added to the care plan in a timely manner for a resident with a history of falls and multiple risk factors, including difficulty walking, Parkinson’s disease, cognitive deficits, and amnesia. The comprehensive care plan, developed after admission, identified the resident as being at risk for falls and included general interventions such as providing prompt assistance, ensuring adequate lighting, and keeping the call light within reach. However, these interventions were not updated or revised from the baseline care plan, despite subsequent falls and identified root causes. The resident experienced two documented falls during their stay. After the first fall, the root cause was determined to be the resident forgetting to lock their wheeled walker, and a visual reminder was recommended as a new intervention. After the second fall, which was associated with an unsteady gait and a urinary tract infection, close observation and neuro-checks were recommended. Despite these findings and recommendations, the care plan was not updated to include the new interventions before the resident was discharged. Staff interviews and record reviews confirmed that the care plan was only updated after the resident had already left the facility, contrary to the facility’s own fall management policy.