Failure to Update Care Plans and Implement Fall Interventions
Penalty
Summary
The facility failed to update and implement fall interventions in the care plans for residents identified as high fall risks, and did not conduct thorough fall investigations. One resident with diagnoses including dementia, psychotic disturbance, and diabetes was documented as moderately cognitively impaired and required supervision for most activities of daily living. Despite being identified as a high fall risk, this resident experienced multiple falls, some unwitnessed, and the care plan was not consistently updated with new interventions following each incident. Staff involved in the falls were not asked to provide witness statements, and management did not systematically document or investigate the circumstances of each fall. Another resident, severely cognitively impaired with diagnoses such as encephalopathy, dementia, and repeated falls, also experienced an unwitnessed fall. The care plan for this resident included an 'alternate call light' intervention, which required staff to visualize the resident every 15 minutes. However, staff interviews revealed that these checks were not documented, and there was no way to verify that the intervention was consistently implemented. Staff could not confirm the last time the resident was visualized prior to the fall, and documentation in the medical record was found to be inaccurate regarding the timing of checks. Facility leadership confirmed that there was no policy or system in place to document 15-minute checks or to keep separate files for fall investigations. The only documentation available was in the electronic medical record, and there was no established process for collecting or reviewing witness statements from staff involved in falls. The lack of documentation and follow-through on care plan interventions and investigations contributed to the facility's failure to ensure a safe environment and adequate supervision to prevent accidents.