Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update care plan interventions for a resident after multiple falls, as required by policy and regulatory standards. Record review showed that a resident with diagnoses of Alzheimer's disease, dementia, and malnutrition, and a BIMS score indicating severe cognitive impairment, experienced several falls over a period of time. Despite these incidents, the care plan did not reflect updated or new interventions to address the resident's fall risk. Incident reports documented each fall, but the care plan remained unchanged regarding fall prevention strategies. Interviews with staff, including an LPN and the DON, confirmed that nurses are responsible for entering interventions into the care plan after a fall. However, it was revealed that while interventions were sometimes documented in progress notes and discussed by the interdisciplinary team, they were not consistently incorporated into the resident's care plan. The DON acknowledged that the process for updating care plans was not always followed, particularly due to reliance on the MDS nurse to finalize interventions, and noted that a new MDS nurse was in training at the time.