Failure to Timely Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with unsteadiness on feet and dementia, who experienced multiple falls. Despite the resident's severely impaired cognition and history of falls, the care plan was not revised in a timely manner to reflect four separate fall incidents. Documentation showed that new interventions were suggested by the interdisciplinary team (IDT) after each fall, such as the use of a hipster device, assessment for appropriate footwear, and cues for frequent rest breaks, but these interventions were not promptly or consistently incorporated into the resident's care plan. Record reviews indicated that the resident's care plan was only updated after a significant delay, and did not include all the falls that had occurred. Staff interviews revealed that while interventions were discussed in daily meetings and some were implemented in practice, the care plan itself was not updated after each fall as required by facility policy. The staff responsible for updating care plans, including the MDS nurse and the DON, acknowledged that care plans should be updated after every fall, but cited staffing limitations and lack of audits as reasons for the oversight. The facility's own policies required that care plans be reviewed and revised after each fall and after each comprehensive and quarterly MDS assessment. However, the care plan for this resident did not reflect the falls on four specific occasions, nor did it document all the interventions that were discussed and implemented by the care team. This failure to update the care plan in a timely and comprehensive manner could affect the delivery of care and services to the resident.