Failure to Update Care Plans and Implement Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure an environment as free from accident hazards as possible by not analyzing or identifying risks for falls, not implementing new interventions to prevent future falls, and not updating care plans after residents experienced falls. Multiple residents with significant medical histories, including cancer, osteoarthritis, COPD, and heart failure, experienced repeated falls. Despite these incidents, staff did not document investigations into the causes of the falls or update care plans with new interventions tailored to prevent recurrence. For one resident, several falls occurred over a period of months, including unwitnessed falls in the restroom, sliding from a recliner and bed due to weakness, and falling while using a walker. Each incident was documented in nursing progress notes, but the care plan was not revised to reflect these events or to add new preventive measures. There was also no documentation of investigations into the causes of these falls or any analysis to identify contributing factors. Similar patterns were observed with other residents who had falls related to reaching for objects, attempting to get a soda, or experiencing lightheadedness. In each case, the care plans were not updated to include the new falls or interventions, and there was no documentation of investigations into the causes. Interviews with staff revealed inconsistent understanding of when and how to update care plans after falls, with some staff unsure if updates were necessary. The facility also lacked a specific policy regarding falls, further contributing to the deficiency.