Failure to Update Care Plan After Falls and New Interventions
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect changes in care needs following multiple falls and the implementation of new safety interventions. The resident, who had a history of falls, left shoulder injury, left hip fracture, and conditions such as deconditioning, limited mobility, vertigo, orthostatic hypotension, and weakness, experienced several falls over a period of time. After each fall, the interdisciplinary team met and decided on new interventions, including the addition of bed and wheelchair alarms to help prevent further incidents. Despite these interventions being implemented, there was no documented evidence that the resident's care plan was revised to include the use of bed and wheelchair alarms. Observations confirmed the presence of these alarms in use, and staff interviews verified their application, but the care plan did not reflect these updates. This failure to update the care plan was confirmed by the Director of Nursing and was not in accordance with the facility's policy or regulatory requirements.