Failure to Update Care Plan and Implement New Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement new interventions to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident, who was dependent on staff for all transfers and toileting and required assistance with showers, experienced multiple falls, including unwitnessed incidents resulting in bruises and skin tears. Despite these occurrences, the resident's care plan was not updated to include new or revised interventions following each fall event. Progress notes documented several fall incidents, but the care plan did not reflect any newly implemented strategies to address these repeated events. The facility's own policy required staff to identify and implement additional or different interventions if falls recurred, but this was not done. Interviews confirmed that falls should have been addressed in the care plan and that new interventions should have been developed, but these actions were not taken.