Failure to Update Care Plan and Implement New Fall Prevention Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls remained as free from accident hazards as possible. Specifically, after the resident experienced two unwitnessed falls, there was no evidence that the resident's care plan was updated to reflect the dates and circumstances of these incidents. Facility policy required that care plans be updated following any significant change in condition, including falls, and that such incidents be discussed with the interdisciplinary team for the implementation of preventative strategies. However, documentation review showed that the care plan did not include information about the falls that occurred. Additionally, the facility did not identify or implement any new fall prevention interventions in response to the resident's falls. There was no documentation in the care plan, physician's orders, progress notes, or nurse's notes indicating that a new, resident-specific intervention was considered or put in place after each fall. This was confirmed by both the Assistant Director of Nursing and the Director of Nursing, who acknowledged that the care plan should have been updated with new interventions following each incident. The resident involved had multiple diagnoses, including senile degeneration of the brain, unspecified dementia, unsteadiness on feet, and movement disorder, and was classified as high risk for falls. The lack of timely care plan updates and absence of new interventions following repeated falls constituted a failure to implement an effective fall prevention program as required by facility policy.