Failure to Update Care Plan with Individualized Fall Prevention Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple diagnoses, including Down syndrome, right shoulder dislocation, Alzheimer's, dementia, intellectual disabilities, and epilepsy, to include an individualized intervention—a fall mat—despite its use at the bedside. The resident was identified as a fall risk due to her medical conditions and history of a fall prior to admission. The care plan, developed after admission, included general fall prevention interventions such as following therapy instructions, monitoring safety, and reviewing past falls, but did not specify the use of a fall mat as an intervention. Observations confirmed that a fall mat was present by the resident's bed, and staff interviews revealed that the mat was used as a precaution because the resident was known to roll out of bed, although she had not fallen since admission. Multiple staff members, including a nursing assistant and registered nurses, acknowledged the presence and purpose of the fall mat but confirmed that it was not documented in the resident's care plan. The facility's care planning policy requires individualized, person-centered care plans developed by the interdisciplinary team, but this intervention was omitted from the written plan.