Failure to Update Care Plan with Fall Prevention Intervention
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan for a resident assessed as high risk for falls. The resident, who had a history of falls, a right femur fracture, dementia, and severe cognitive impairment, was dependent on staff for all activities of daily living. After an unwitnessed fall, the interdisciplinary team (IDT) recommended the use of non-skid socks during ambulation to reduce fall risk. However, this intervention was not incorporated into the resident's care plan, despite being discussed and agreed upon during an IDT meeting. Interviews with facility staff, including the Quality Assurance nurse and the Director of Nursing (DON), confirmed that the recommendation for non-skid socks was not added to the resident's fall risk care plan. The facility's policy requires care plans to be updated when there is a significant change in the resident's condition or after relevant team recommendations, but this process was not followed. As a result, the resident's care plan did not reflect all necessary interventions to address their identified fall risk.