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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 26, 2024
Corrected date: February 5, 2025
Citation Details None | Plan of Correction: ApprovedJanuary 21, 2025 What corrective actions(s) will be accomplished for the resident found to have been affected by the deficient practice? I. The following actions were accomplished for those residents found to have been affected by the deficient practice: The affected resident's (Resident #1) care plan was modified/updated to include monitoring q30 minutes. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: The facility will conduct a review of residents with a history of two or more falls over the past six months to identify those who may require more frequent monitoring to minimize the risk for falls. DNS or designees will conduct an audit on residents who have a history of two or more falls in the past six months. The audit will ensure that a new fall risk evaluation is completed, and that the care plan is revised and updated to reflect modifications to frequency of monitoring, if applicable. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur; III. The following system changes will be implemented to ensure that the deficient practice does not recur: The facility's policy and procedure PC67, titled Fall Reduction and Injury Prevention Program, has been reviewed. It has been determined that no revisions are necessary at this time. All active nursing staff will be re-in-serviced on the Fall Prevention policy by the Nursing Educator(s). All active licensed registered nursing staff will be re-educated on updating residents' plans of care to include modifications in monitoring frequency, as applicable. An audit tool has been developed to systematically monitor the completion of post-fall risk evaluations, updates to care plans, and, where applicable, modifications to the monitoring frequency. How the corrective actions(s) will be monitored to ensure deficient practice will not recur, i.e., what quality assurance program will be put into practice IV. The facility's compliance will be monitored utilizing the following quality assurance system: DNS or designee will report assessment results for residents who have a history of two or more falls in the past six months to the Quality Assurance Performance Improvement (QAPI) committee to ensure compliance with post-fall assessments, care plans, and monitoring. The completion of staff education and compliance with post-fall assessments, care plans, and monitoring will be reported to the Quality Assurance Performance Improvement (QAPI) committee weekly for one month and then monthly for three months, or until compliance is achieved. Responsible Person: Yves Pascal, Director of Nursing |