Failure to Update Care Plans After Major Injury Falls
Penalty
Summary
The facility failed to update and revise the comprehensive person-centered care plans for two residents following unwitnessed falls that resulted in major injuries. For one resident with a history of falls and multiple diagnoses including muscle weakness and lack of coordination, the most recent care plan had not been updated since several months prior to a significant fall event. This resident attempted to get out of bed unassisted, fell, and sustained multiple injuries including a head laceration, eye injury, right humerus fracture, and right femoral fracture. The care plan in place at the time only included general fall prevention interventions and did not reflect the recent incident or any new interventions tailored to the resident's changed condition. Another resident, also with a history of falls and diagnoses such as muscle weakness, lack of coordination, and dementia, experienced a severe unwitnessed fall resulting in a subdural hematoma, traumatic subarachnoid hemorrhage, hypotension, and complex lacerations to the head and face. The care plan for this resident had not been revised since several months before the incident, despite multiple prior falls being documented. The interventions listed were general in nature and did not address the specific circumstances or injuries resulting from the most recent fall. Interviews with facility staff, including MDS coordinators and social workers, revealed that while audits and cross-referencing of care plans were performed, there was a lack of timely updates to care plans following significant changes in resident condition, such as falls with major injury. Staff acknowledged that significant changes, such as fractures after a fall, should prompt reassessment and care plan revision, but this was not consistently done. The facility's own policy requires comprehensive care plans to be updated to reflect measurable objectives and interventions based on current assessments, which was not followed in these cases.