Failure to Update Care Plan After Resident Fall and Therapy Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was as free from accident hazards as possible and did not provide adequate supervision to prevent accidents for a resident with multiple risk factors. The resident, who had diagnoses including dementia, diabetes mellitus type 2, unsteadiness on feet, long-term use of anticoagulants, and general weakness, experienced a fall with injury. The resident had severely impaired cognition and an activated Power of Attorney for Healthcare. On the day of the fall, the resident attempted to ambulate independently to the restroom, using a walker and wearing gripper socks, but fell and sustained a head injury. Staff responded after hearing the resident call for help and observed the walker on the resident's chest. Following the fall, the facility referred the resident for physical and occupational therapy, and therapy staff determined that the resident required assistance of one staff member with a gait belt for all transfers and ambulation. However, the resident's care plan was not updated to reflect these new recommendations, and nursing and CNA staff continued to believe the resident was independent with transfers and ambulation unless assistance was requested. Communication of the therapy recommendations occurred during a morning meeting, but the care plan was not revised, and staff relied on outdated information. This failure to update the care plan and ensure all staff were aware of the resident's current needs contributed to the deficiency.