Failure to Revise Care Plan After Resident Fall with Fracture
Penalty
Summary
The facility failed to ensure that appropriate post-fall interventions were developed and implemented through care plan revision for one resident following a fall that resulted in a fracture. According to the facility's policy, care plans must be updated when a resident experiences a significant change in condition, such as a fall. Review of the resident's electronic medical record and care plan revealed that after the resident experienced a fall with a fracture, there were no updates or revisions made to the care plan to address new or revised interventions, identification of causative or contributing factors, enhanced supervision, environmental modifications, or individualized fall-prevention strategies. The resident involved had multiple diagnoses, including a fracture of the neck of the right femur, encephalopathy, bone density disorders, rhabdomyolysis, dysphagia, and cognitive communication deficit, and was assessed as having severe cognitive impairment. Despite the resident's return from the hospital and a significant change assessment being completed, the care plan was not updated to reflect the fall and subsequent fracture. Interviews with facility staff confirmed that the care plan was not revised as required following the incident.