Failure to Update Care Plan for Fall Interventions
Penalty
Summary
The facility failed to review and revise the person-centered care plan to reflect the current condition of a resident who was at risk for falls. Specifically, the care plan for a male resident with diagnoses including type 2 diabetes, essential hypertension, muscle weakness, and lack of coordination was not updated to include interventions for falls related to unsteadiness during transfers, despite these needs being identified. The care plan had last been revised for falls interventions over two years prior, and no updates were made to address the resident's current condition and need for staff assistance during transfers. Interviews with the DON and MDS Coordinator confirmed that it was the responsibility of the MDS Coordinator to update care plans with appropriate interventions so staff would know how to assist residents. However, the MDS Coordinator could not provide a reason for the lack of updates to the resident's care plan. The facility's policy required comprehensive, person-centered care plans with measurable objectives and targeted interventions, but this was not followed in the case of this resident.