Failure to Revise and Implement Fall Risk Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to implement and revise a care plan for a resident assessed at high risk for falls, as required by its own policy and procedures. The resident, who had a history of falls prior to admission and multiple medical diagnoses including metabolic encephalopathy, abnormal gait, and severe cognitive impairment, was admitted with existing skin injuries and was identified as high risk for falls upon admission. The initial care plan included interventions such as visual checks every two hours, maintaining a well-lit room, keeping the bed in the lowest position, and ensuring brakes were applied during transfers. However, the care plan was not updated or revised after the resident experienced subsequent falls. On one occasion, the resident fell in the hallway while ambulating with a front-wheeled walker and sustained bruises, swelling, and an open wound on the forehead. Documentation did not indicate that staff supervised or assisted the resident during ambulation, despite the care plan's requirements. Following this fall, there was no evidence in the medical record that the care plan was updated to reflect new interventions or to address the increased fall risk, even though the resident's fall risk score increased and the physical therapist recommended supervision at all times. The resident experienced another fall in their room, resulting in additional injuries, including abrasions and bruising to the head and face. Despite these incidents and recommendations from the rehabilitation department for increased supervision, the care plan remained unchanged from its original version. Interviews with nursing staff and the Director of Nursing confirmed that the care plan was not updated after the falls, contrary to facility policy, which requires care plan updates within 72 hours of a fall to develop or revise interventions.