Failure to Implement Fall Interventions on Care Plans
Penalty
Summary
Facility staff failed to implement fall prevention interventions for two residents following documented falls. For one resident, clinical record review showed a fall occurred, but no new interventions were added to the care plan as required. The Director of Nursing (DON) confirmed that interventions should be added to the care plan but was unable to provide evidence that this was done. The facility's own policy, which requires immediate team meetings and updating care plans with new interventions after a fall, was not followed. Another resident experienced multiple falls over several months, yet the care plan was not updated with new interventions after any of these incidents. The DON again acknowledged the requirement but could not show that interventions were implemented. Facility documentation reviewed confirmed that staff are required to establish and implement new interventions on the care plan after a fall, but this procedure was not followed for either resident.