Failure to Update and Revise Care Plan Interventions for Fall Prevention
Penalty
Summary
The facility failed to periodically review and revise the care plan for a resident with a history of dementia, muscle weakness, unsteady gait, and repeated falls. The resident's care plan included an intervention for a floor mat at bedside to prevent falls, but this intervention was not updated or removed when it was no longer in use. Observations on multiple occasions confirmed that no floor mat was present at the resident's bedside, despite it being listed in the care plan and visible to CNAs in their electronic charting system. Interviews with staff revealed confusion and lack of clarity regarding the implementation and updating of care plan interventions. CNAs reported not seeing a floor mat in use and were unsure how to access or interpret care plans, often relying on charge nurses for direction. The MDS coordinator and DON acknowledged that the floor mat intervention remained on the care plan due to it being added by a previous nurse years prior, and that it was not part of the current plan of care. However, the intervention was still listed in the system accessed by direct care staff, leading to inconsistencies between documented care plans and actual care provided. The facility's policies required the interdisciplinary team to review and revise care plans after each assessment and following falls, but the care plan for this resident was not appropriately updated to reflect current interventions. The lack of timely revision and removal of outdated interventions from the care plan resulted in discrepancies between the care plan and the care actually provided, as well as confusion among staff regarding which interventions should be implemented.