Failure to Revise Care Plans with Current Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect current interventions for two residents with a history of falls. For one resident admitted with repeated falls, the Interdisciplinary Team (IDT) added a fall mat as an intervention after a fall, and the mat was observed in use during a site visit. However, the resident's care plan was not updated to include this intervention. Similarly, another resident with multiple falls had several interventions in place, including the use of side rails, a fall mat, and placement in a common area for closer supervision, as confirmed by staff interviews and direct observation. Despite these interventions being implemented, the care plans for both residents did not document the use of the fall mat, call light within reach, or placement in a common area as fall prevention strategies. Staff interviews, including those with a CNA, LPN, MDS coordinator, and DON, confirmed that the care plans were not revised to include these interventions, even though facility expectations required such updates when new interventions were added.