Failure to Update Care Plans and Complete Fall Investigations
Penalty
Summary
The facility failed to ensure that residents' care plans were updated to include interventions implemented after falls, and did not thoroughly complete fall investigations as required by facility policy. For three residents reviewed, care plans did not reflect new or revised interventions following multiple fall incidents, such as increased monitoring, use of anti-roll back wheelchairs, or placement of floor mats. In several cases, interventions that were implemented post-fall were not documented in the care plan, and there was no evidence that staff were consistently informed or able to follow these interventions. Additionally, fall investigations were incomplete for two residents, with missing staff witness statements and incomplete documentation of the circumstances surrounding the falls. The facility's own policies required that all incidents be thoroughly investigated, including obtaining written statements from all witnesses and completing all sections of the accident and incident reports. However, in multiple instances, only partial information was collected, and staff statements were not included, limiting the ability to determine the cause of the falls and the effectiveness of interventions. The residents involved had significant cognitive impairments and were at high risk for falls, as indicated by their medical diagnoses and fall risk assessments. One resident with severe dementia experienced multiple falls in the dining room, another with toxic encephalopathy and muscle weakness had unwitnessed falls resulting in injuries, and a third resident with hemiplegia and moderate cognitive impairment was transferred by a single CNA despite a care plan requiring two-person assistance. In each case, the lack of updated care plans and incomplete investigations contributed to the deficient practice.