Failure to Update Care Plans with Fall Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that fall interventions were incorporated into person-centered care plans following falls for five out of seven residents reviewed. Each of these residents experienced a fall during a specified period, but their care plans were not updated to reflect new or revised interventions addressing the specific incidents. The absence of these interventions was confirmed through record reviews, care plan audits, and interviews with facility staff, including the RN Supervisor, Restorative CNA, DON, and Administrator. The residents involved had significant medical histories and varying degrees of cognitive and physical impairment. For example, one resident had severe cognitive impairment and multiple fractures, another had muscle wasting and hemiplegia following a stroke, and others had diagnoses such as congestive heart failure, encephalopathy, and gait abnormalities. Despite these complex needs and documented falls, their care plans did not include interventions specific to the falls that occurred during the review period. Interviews with facility staff revealed a lack of clarity and follow-through regarding the process for updating care plans after a fall. The RN Supervisor, who also served as the MDS Coordinator, acknowledged that fall interventions were not added to the care plans for the incidents in question. The DON and Administrator both confirmed that the responsibility for updating care plans with fall interventions rested with the MDS Coordinator, and that this had not been done for the affected residents. The facility's policy and procedure for care plans was requested but not provided during the survey.