Failure to Revise Care Plans and Implement Adequate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that two residents received adequate interventions to prevent accidents, specifically falls, despite their known high risk and history of previous incidents. One resident with significant cognitive impairment, muscle weakness, and a history of falls experienced multiple falls within a short period. After the first fall, which resulted in a skin tear and a subsequent hospital evaluation revealing a brain hemorrhage, the care plan was updated with general safety interventions. However, following a second fall that resulted in another head injury and bleeding, the care plan was not revised to include any new or additional interventions, and there was no documentation of further neurological checks or post-fall assessments as required by facility policy. Another resident, also identified as high risk for falls due to impaired mobility, cognitive impairment, and a history of stroke, experienced a fall that was witnessed by staff. Although an incident report was completed and a physical therapy evaluation was ordered as an intervention, the resident refused therapy, and no alternative interventions were considered or implemented. The care plan was not updated to reflect the attempted intervention or to address the continued risk of falls, and the effectiveness of the intervention was not evaluated. Interviews with the Director of Nursing confirmed that in both cases, the facility did not follow its own policies regarding post-fall care planning and intervention. The care plans were not reviewed or revised after subsequent falls, and required documentation and monitoring were lacking. These failures resulted in a lack of adequate supervision and accident prevention measures for residents at high risk for falls.