Failure to Revise Care Plan with Fall Interventions
Penalty
Summary
Facility staff failed to review and revise the care plan to include fall interventions for one resident. Specifically, after a fall incident, a progress note indicated that nonskid strips should be placed by the resident's bedside as a new intervention. However, this intervention was not added to the resident's care plan, despite documentation in a device assessment that it had been. Multiple staff interviews revealed inconsistent knowledge about whether nonskid strips were in place for the resident, and staff relied on care plans and other documentation to implement interventions. Housekeeping staff were responsible for removing nonskid strips after resident discharge, but there was no clear record of the intervention being implemented for the resident in question. A review of facility policies showed that interventions identified after falls or through device assessments were to be incorporated into the care plan and reviewed by licensed nurses. The care plan for the resident did not reflect the intervention for nonskid strips, even though it was documented elsewhere as necessary. The deficiency was identified through observation, staff interviews, and review of clinical records and facility documentation, and was communicated to facility leadership.