Failure to Update Care Plan and Provide Adequate Supervision After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and individualized interventions to prevent accidents, specifically falls. The resident, who had a history of left femur fracture, unsteadiness, diabetes mellitus type II, and osteoarthritis, was assessed as having moderate cognitive impairment and functional limitations in both upper and lower extremities. Despite being identified as a fall risk and experiencing multiple falls over several months, the resident's care plan was not updated to address actual falls, including an unwitnessed fall that resulted in abrasions and bruising. The care plan contained general fall prevention interventions but was not revised after each incident to reflect new or individualized strategies based on the circumstances of the falls. Interviews with facility staff confirmed that the care plan should have been reviewed and updated after each fall, particularly following the most recent unwitnessed fall. The facility's policy required reassessment and immediate updating of the interdisciplinary plan of care after each fall, but this was not done. The lack of timely review and modification of the care plan after repeated falls constituted a failure to provide adequate supervision and assistance devices, as required to prevent further accidents.