Failure to Revise Care Plans After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that care plans were revised and appropriate for three out of four residents reviewed for comprehensive care plans. Specifically, the facility did not update or revise the fall care plans with new interventions after multiple falls occurred for two residents. For one resident, there were 11 falls out of 13 incidents where the care plan was not updated to include new interventions, despite documentation of unwitnessed and witnessed falls, some resulting in abrasions, skin tears, and hospital transfer. The care plan and Kardex did not reflect changes or new strategies to address the ongoing risk and incidents of falls, even though the facility's own policies required ongoing assessment and revision of care plans as residents' conditions changed or when desired outcomes were not met. Another resident experienced a fall, and the care plan was not updated to include new interventions following the incident. The fall care plan for this resident included interventions such as bed positioning, call light education, and non-skid footwear, but after the fall, no new interventions were added to the care plan. Staff interviews confirmed that recommendations and interventions discussed in meetings were not consistently added to the care plans or the Kardex, which are used by CNAs and other staff to guide resident care. The lack of timely updates to care plans meant that staff did not have access to the most current and individualized fall prevention strategies for these residents. Interviews with facility staff, including the NHA, DON, MDS coordinator, and CNAs, revealed inconsistencies in how fall interventions were communicated and implemented. Staff often relied on verbal communication or checked with nurses rather than referencing updated care plans or the Kardex. The MDS coordinator acknowledged that care plans were not always updated promptly after falls and that a facility-wide audit of care plans was underway but incomplete. The failure to revise care plans as required by facility policy and federal regulations led to deficiencies in the provision of person-centered care and fall prevention for residents at risk.