Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents following fall incidents. For four out of five residents reviewed, the care plans were not updated to reflect new falls and the interventions that were put in place. Specifically, after each fall event, interventions such as low beds, clutter-free areas, increased rounding, lab orders, and nighttime snacks were implemented by staff, but these were not documented in the residents' care plans. This lack of documentation was observed despite the facility's policy requiring care plans to be updated after changes in a resident's condition or following incidents such as falls. Residents affected had significant medical histories, including conditions such as stroke, hemiplegia, Alzheimer's disease, muscle weakness, and impaired cognition. These residents were dependent on staff for activities of daily living and were at high risk for falls. In several cases, falls were witnessed or discovered by staff, and immediate interventions were initiated, such as neuro checks and physical assessments. However, the care plans did not reflect the most recent falls or the specific interventions that were implemented in response to those incidents. Interviews with facility staff, including the DON, MDS Coordinator, nurses, and CNAs, revealed that while interventions were communicated verbally during shift changes and through other informal means, the formal care plans were not consistently updated. The MDS Coordinator relied on notifications from the Fall Committee or Unit Managers to update care plans, and if not informed, updates were not made. Staff acknowledged that interventions were being carried out but admitted that documentation in the care plans was lacking. Facility policies reviewed also emphasized the need for interdisciplinary involvement and timely updates to care plans following changes in resident condition, which was not consistently followed.