Failure to Assess and Update Care Plans for Recliner Safety and Fall Prevention
Penalty
Summary
The facility failed to assess and address the safety needs of three out of five sampled residents who either experienced falls related to recliner use or lacked access to their recliner controls. For one resident with multiple comorbidities including Alzheimer's, osteoarthritis, and congestive heart failure, there were repeated falls, including one from a recliner with the footrest elevated. Despite a high fall risk and changes in condition following hospitalization and hospice admission, the resident's care plan was not updated to reflect new transfer and supervision needs, nor were interventions for safe recliner use documented. The care plan in the electronic medical record remained outdated, and temporary paper care plans were not integrated or accessible to all staff. Another resident with severe cognitive impairment experienced a fall from bed, and although a lift chair/recliner assessment was eventually completed, the care plan did not include safety measures related to recliner use. A third resident, cognitively intact but with Parkinson's and a history of falls, fell while attempting to transfer from a recliner. Interventions identified after the fall, such as monitoring the floor for hazards, were not added to the care plan, and there were no documented interventions for safe recliner use. In all cases, the lack of timely and comprehensive care plan updates contributed to inadequate supervision and accident prevention. Staff interviews revealed inconsistent knowledge and education regarding recliner safety, with CNAs and nurses relying on personal judgment or informal communication rather than standardized protocols. Education on fall prevention was provided, but there was no documented or comprehensive education on recliner safety. Policies required care plans to address all aspects of resident care, including the use of recliners, but these were not consistently followed. Documentation systems did not allow for timely updates to care plans after falls, and staff were unclear on where to find or document recliner safety interventions, leading to gaps in supervision and accident hazard prevention.