Failure to Update Care Plan with Fall Prevention Interventions After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following a fall, as required by policy and regulation. After the resident, who had a history of falls and multiple high-risk diagnoses including dementia, Alzheimer's disease, and a recent femur fracture, experienced an unwitnessed fall, the care plan was not promptly updated to reflect new fall prevention interventions or the need for 1:1 supervision. Although staff verbally discussed and implemented increased supervision, this intervention was not formally documented in the resident's care plan or communicated consistently across all shifts. The resident was identified as high risk for falls upon admission, with a Fall Risk Assessment score indicating the need for heightened precautions. Despite this, after the initial fall, the care plan interventions remained generic and did not include specific, measurable objectives or timeframes tailored to the resident's updated needs. Staff interviews revealed that while there was an understanding among caregivers and nurses that the resident required constant monitoring, this was not reflected in the written care plan or the Kardex, which serves as a quick reference for CNAs. Facility policy required that care plans be updated immediately following a fall or change in condition, with new interventions documented by the end of the shift. However, both nursing and administrative staff acknowledged that the care plan was not revised in a timely manner to include the 1:1 supervision intervention. This lack of documentation and formal communication led to inconsistencies in care and delayed the implementation of necessary safety measures for the resident.