Failure to Update Baseline Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a baseline care plan for falls was continuously evaluated and updated to reflect interventions identified as a result of fall investigations for a resident with neurocognitive disorder with Lewy bodies and polyneuropathy. Upon admission, the resident was noted to have severe cognitive impairment, a history of falls, and required supervision for transfers. The initial baseline care plan did not identify the resident's level of fall risk or include appropriate fall prevention interventions. Following two witnessed falls in the dining area, additional interventions such as one-to-one supervision, increased staff assistance, and specific instructions for transfers and ambulation were identified during fall investigations. Despite these incidents and the identification of new interventions, the baseline care plan was not updated to reflect the changes. The DON confirmed that although the resident was recognized as high fall risk at admission and a baseline care plan was created, it did not specify the risk level or include the necessary interventions to mitigate future falls. The facility's policy requires that a baseline care plan be developed and implemented within 48 hours of admission to address health and safety concerns, but this was not followed in the resident's case.