Failure to Accurately Review and Revise Care Plans After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were accurately reviewed and revised following falls for two residents. For one resident with dementia, bipolar disorder, a history of falls, severe cognitive impairment, unilateral lower extremity impairment, and dependence on a wheelchair and extensive assistance for ADLs, a fall risk care plan initiated after an unwitnessed fall documented the use of a chair/bed alarm and directed staff to ensure the device was in place as needed. However, the resident’s record showed no evidence that any alarm was ever in use during the stay, and a CNA interview confirmed the resident did not have a wheelchair alarm. The DON stated that the chair/bed alarm intervention was entered erroneously and that the facility does not use alarms. For another resident with sequelae of cerebral infarction, seizures, and left-sided hemiplegia who required supervision for mobility and ADLs and used a walker or wheelchair, an incident report documented that the resident was found on the floor in a sitting position after sliding off the bed. The post-occurrence investigation stated that the resident’s care plan was reviewed and revised. However, review of the fall risk care plan, last revised on the date of the fall, showed only a notation that the resident was found sitting on the floor at the foot of the bed and did not include any new safety interventions implemented after the fall. During interview, the DON acknowledged that no intervention was present on this resident’s care plan and could not explain why it was not entered.
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