Failure to Revise Care Plan for Fall Interventions
Penalty
Summary
The facility failed to revise the comprehensive care plan to include updated fall prevention interventions for a resident with multiple medical conditions, including cerebral infarction, Alzheimer's disease, dementia with behaviors, diabetes, osteoarthritis, chronic pain, dysphagia, and muscle weakness. Despite documented recommendations from both the physician and occupational therapy to keep the wheelchair seat in the lowest position with anti-rollback devices and to tilt the wheelchair seat for safety, these specific interventions were not updated in the resident's care plan. The facility's own policies require that care plans be revised to reflect new or changed interventions following a fall or identification of new risk factors. Observations over several days confirmed that the resident consistently used a bolster bed and a wheelchair equipped with anti-rollback devices and a tilted seat. During an interview, the DON acknowledged that these interventions were in place but confirmed that the comprehensive care plan had not been revised to include the anti-rollback devices, the tilted wheelchair seat, or the bolster bed. This omission was identified through review of facility policy, medical records, direct observation, and staff interview.