Failure to Revise and Implement Comprehensive Fall Care Plans
Penalty
Summary
The facility failed to implement and revise comprehensive care plans to address falls for two residents who were identified as being at risk for falls. For one resident with multiple fractures, diabetes, and muscle wasting, the care plan noted a risk for falls and included interventions such as ensuring the call light was within reach and conducting environmental rounds. However, after the resident experienced a fall while attempting to remove lift sling straps from her wheelchair, the new intervention to tuck the straps under the resident was not added to the care plan. Additionally, the intervention to educate the resident about asking for assistance with sling placement was not documented as completed. For another resident with vascular dementia, behavioral disturbances, and a history of falls, the care plan included several interventions to reduce fall risk, such as keeping supplies within reach and using a floor mat. Despite this, after the resident was observed crawling in the hallway, the root cause was identified as the resident purposefully placing himself on the floor to crawl. The interdisciplinary team determined that the resident should be care planned to crawl on the floor when desired, but this new intervention was not updated in the care plan. In both cases, the facility's fall policy required that care plans be revised with each fall and that new interventions be implemented as appropriate. The failure to update the care plans with new interventions following falls was confirmed by the facility administrator, indicating noncompliance with the facility's own policy and regulatory requirements for comprehensive care planning.