Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect care needs following multiple falls. A resident with a history of repeated falls was admitted with multiple diagnoses and was assessed as cognitively intact. The facility's records showed that the resident experienced falls on two separate occasions in August, and documentation from fall investigations indicated that the care plan was updated to cue and encourage the resident to use the call light and wait for help. However, review of the resident's fall care plan revealed that after the second fall, no new revision or intervention was documented to address the most recent incident. Interviews with facility staff confirmed that the expected process after a fall was to update the care plan with a new intervention. The Resident Care Manager/LPN acknowledged that a new intervention should have been added after the second fall but stated it was missed. The Director of Nursing/RN also confirmed the expectation that the care plan be updated after each fall. This deficiency was identified through interview and record review, as the care plan did not reflect the resident's most current care needs following the second fall.