Failure to Update Care Plan with Fall Prevention Intervention
Penalty
Summary
The facility failed to review and revise the interdisciplinary care plan to accurately reflect interventions for a resident with diagnoses including dementia, generalized muscle weakness, and cognitive communication deficit. The resident experienced a fall in their room while attempting to retrieve an item from a drawer. Following the fall, a licensed nurse assessed the resident, performed neuro checks, and documented that there were no injuries. The nurse's post-fall documentation included a recommendation for the bed to be kept in a low position as an intervention to prevent further falls. Upon review, it was found that the resident's care plan for falls, which had been initiated and revised prior to and after the fall, did not include the intervention of keeping the bed in a low position, despite this being documented in the nurse's note. Both the unit manager and the DON confirmed that the care plan should have been updated to include this intervention, as it is a standard measure for fall prevention. The deficiency was identified through record review and staff interviews, which confirmed that the care plan did not accurately reflect the interventions in place for the resident.