Failure to Revise Fall Care Plan After Multiple Resident Falls
Penalty
Summary
Licensed nursing staff failed to revise the fall care plan for a resident after multiple falls, as evidenced by record reviews and staff interviews. The resident, who was admitted with diagnoses including paranoid schizophrenia and bipolar disorder, had fluctuating capacity to understand and make decisions, and required supervision for activities of daily living due to moderately impaired cognitive skills. Despite documented falls on several occasions, the care plan interventions were not updated after each incident, and no new interventions were developed to address the recurring falls. Interviews with nursing staff confirmed that care plans should be revised after every fall, and that the lack of updated interventions meant there were no additional measures in place to minimize future falls. The facility's policy required staff to implement additional or different interventions if falls reoccurred, or to justify the continuation of current interventions, but this was not followed. As a result, the resident did not have effective interventions in place to minimize future falls and injuries.