Failure to Document IDT Post-Fall Assessments and Update Care Plans
Penalty
Summary
The facility failed to complete Interdisciplinary Team (IDT) post-fall assessments and implement post-fall interventions for three residents identified as high risk for falls. For each resident, multiple falls occurred, but the clinical records lacked documentation of IDT reviews and updates to care plans with new interventions following these incidents. Specifically, Resident B, with a history of stroke, epilepsy, and dementia, experienced several falls without corresponding IDT review or care plan updates. Resident E, diagnosed with senile degeneration of the brain, convulsions, and gait issues, also had multiple falls without documented IDT review or added interventions. Resident F, with a history of traumatic brain injury, Parkinson's disease, and repeated falls, similarly lacked IDT review and care plan modifications after several falls. During an interview, the DON acknowledged that while IDT reviews were conducted during morning meetings, there was a failure to document the root cause analysis, the IDT review itself, and to update care plans with new interventions for some falls. The facility's policy requires the IDT to review each fall and modify the plan of care as indicated, but this process was not followed or documented as required for the residents involved.