Failure to Update Care Plan and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that adequate assistive devices and supervision were in place to prevent falls for a resident with a history of multiple falls. Despite the resident being identified as high risk for falls due to recent admission, prior falls, and use of psychotropic, pain, and narcotic medications, the care plan was not updated with appropriate interventions after each fall. The resident experienced falls on several occasions, including incidents where the wheelchair brakes were not locked, the resident rolled out of bed, and dizziness led to a fall resulting in a head injury. Although the interdisciplinary team (IDT) reviewed each fall and discussed possible interventions such as auto-lock brakes, fall mats, and bolsters, these interventions were not consistently implemented or documented in the resident's care plan. Interviews and record reviews revealed that the resident did not receive some of the recommended interventions, such as bolsters or a fall mat, and the care plan was not updated to reflect new or revised interventions after each fall event. The facility's policy required immediate interventions and care plan updates following falls, but these steps were not followed. The President of Clinical Operations confirmed that the care plan should have been updated after new interventions were determined, acknowledging that this did not occur for the resident in question.