Failure to Update Care Plan with Preventative Interventions After Multiple Falls
Penalty
Summary
The facility failed to update and revise the care plan for a resident after multiple falls, as required by its own Fall Prevention Program policy. The policy specifies that all residents should be assessed for fall risk at admission, quarterly, and after any significant change in condition, with the care plan updated to reflect new risks and appropriate interventions. Despite the resident experiencing five separate falls, the care plan only documented post-fall actions such as neuro checks and notifications to responsible parties and medical staff, without adding or revising any preventative interventions to address the ongoing risk of falls. The resident involved had a history of hemiplegia and hemiparesis following cerebrovascular disease, hypertension, and blindness, and was admitted with these diagnoses. After one of the falls, the resident was found with a laceration and hematoma and required emergency room evaluation. During an interview, the ADON confirmed that no new interventions or care plan revisions were implemented following any of the falls, acknowledging that the care plan should have been updated with new fall prevention strategies after each incident.