Failure to Update Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with measurable objectives and timetables to address the needs of a resident who had a history of multiple falls. The resident, who had a left hip fracture, unsteadiness on her feet, diabetes mellitus type II, osteoarthritis, and moderate cognitive impairment, experienced several falls during her stay. Despite these incidents, the care plan was not updated to reflect the actual falls, their causes, or to include new interventions after each event, particularly following an unwitnessed fall that resulted in an abrasion and bruising. Review of the resident's care plan showed that while some interventions were listed, such as fall risk signage, ensuring call lights were within reach, and providing non-skid footwear, the plan did not address the specific circumstances or root causes of the repeated falls. The care plan also lacked updates after significant events, including the most recent unwitnessed fall. Interviews with the resident revealed she was aware of her frequent falls and sometimes attempted to transfer herself if assistance was delayed, despite needing supervision or assistance with transfers. Staff interviews confirmed that the care plan should have been reviewed and updated after each fall to identify root causes and implement appropriate interventions. However, the care plan remained unchanged after the most recent incident, and the facility's policy requiring comprehensive, person-centered care planning with measurable objectives and timeframes was not followed. This failure resulted in the resident's individualized needs not being addressed in a timely manner.