Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise the care plans for three out of four sampled residents after each experienced a fall, as required by their own policy and regulatory standards. For one resident with congestive heart failure and multifocal motor neuropathy, the care plan documented several previous falls and interventions, but after a non-injury fall while transferring from bed without assistance, no new intervention was added to the care plan. Another resident with atrial fibrillation and a history of falls had a care plan indicating risk for falls, but after a fall resulting in a major injury while ambulating, the care plan was not updated to reflect new interventions. The resident confirmed having fallen and sustaining a shoulder injury. A third resident with dementia and Alzheimer's disease had a care plan noting multiple prior falls and interventions, but following a minor injury fall while transferring from bed, the care plan was not revised to include additional interventions. The Director of Nursing confirmed that the care plans for these residents should have been updated to reflect new fall prevention interventions after each fall event. The facility's policy requires staff and practitioners to identify possible causes and implement pertinent interventions within 24 hours of a fall, and to re-evaluate and reconsider interventions if falls continue. Despite this, the care plans for the affected residents were not revised after their most recent falls, as documented in the facility's records and confirmed through staff and resident interviews.