Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that two residents who experienced falls had these incidents incorporated into their individualized care plans. For one resident, who had a history of Alzheimer's disease, repeated falls, and other significant medical conditions, a fall that occurred in October was not added to her care plan. Although previous falls had been care-planned with specific interventions, the most recent fall was only documented in a change in condition assessment, with no corresponding update to the care plan. Similarly, another resident with Alzheimer's disease, schizophrenia, diabetes, COPD, and muscle weakness experienced an unwitnessed fall in the hallway, resulting in a forehead injury and subsequent transfer to the emergency room. Despite this event being documented in progress notes and a change in condition assessment, the fall was not added to the resident's care plan. This resident had prior falls that were care-planned, and interventions for fall risk were in place, but the most recent incident was not addressed in the care plan. Interviews with facility staff, including the MDS nurse responsible for care plans, revealed that falls should be documented and care plans updated accordingly. The MDS nurse indicated that care plans are typically updated the day after a fall unless the resident is sent out, in which case updates occur upon return. The administrator and DON confirmed that the falls should have been care-planned and acknowledged that failure to do so could result in staff not knowing how to care for the residents following such incidents.