Failure to Timely Revise Care Plan with Fall Interventions After Multiple Falls
Penalty
Summary
The facility failed to timely revise the care plan with appropriate fall interventions for a resident with a history of falls and multiple risk factors. The resident, diagnosed with Alzheimer's disease, diabetes mellitus, and Parkinson's disease, required moderate assistance for transfers, had severe cognitive impairment, and had experienced two or more falls since admission. Despite being identified as high risk for falls, the care plan was not updated promptly after several fall incidents to reflect new interventions discussed by the interdisciplinary team (IDT). Multiple fall incidents occurred over several days, including the resident being found on the floor in various locations such as the dining room, next to the bed, and in front of a recliner. In some cases, alarms intended to alert staff did not function as intended, such as a wheelchair alarm with a string that was too long. The IDT discussed interventions like placing the resident near the nursing station with a tray table, shortening alarm strings, involving family for supervision, and increasing toileting and repositioning frequency. However, these interventions were not promptly incorporated into the resident's care plan. Interviews with nursing staff and the DON revealed that staff were unable to clearly articulate additional fall prevention interventions beyond the use of alarms, and acknowledged that the care plan had not been revised in a timely manner to reflect the interventions discussed after each fall. The facility's policy requires care plans to be updated when there is a significant change in the resident's condition or when desired outcomes are not met, but this was not followed in the resident's case.