Failure to Update Falls Care Plan After Resident Injury
Penalty
Summary
The facility failed to update a resident's falls care plan with new interventions following a significant fall event. The resident, who had a history of bipolar disorder with mood and behavioral disturbances, was initially not identified as being at risk for falls, and the only intervention listed was for nursing staff to complete a fall risk assessment per facility protocol. Despite the resident experiencing a traumatic fall resulting in multiple fractures and requiring maximum staff assistance with activities of daily living, the care plan was not revised to reflect the increased fall risk or to include additional interventions. The fall risk review completed after the incident did not acknowledge the recent fall or the resident's new health conditions that predisposed them to further falls. Staff interviews revealed confusion regarding the documentation of fall history and risk status, with the DON indicating that the fall risk review did not consider the most recent fall. The facility's policies require care plans to be reviewed and updated with any significant change in condition and mandate additional interventions after a fall, but these procedures were not followed for this resident. The lack of timely and appropriate updates to the care plan contributed to the deficiency identified during the survey.