PruittHealth Moncks Corner in South Carolina was cited after the facility failed to protect a resident known for falling. The resident left the facility unattended and fell out of their wheelchair in the facility’s courtyard. This facility was also recently cited for failing to review and revise the care plan for a resident who was known to put non-edibles in her mouth. The post regarding this citation can be read here.
The resident in this citation had falling identified as a “problem area” in their care plan. The care plan had the following listed as interventions to help the resident:
– Resident prefers to wear shoes when out of bed
– Resident needs a night light on to help see at night
– Remind resident to ask for assistance when moving around
– Monitor for changes in resident’s condition that may warrant increased supervision/assistance
After the resident fell from the wheelchair, the care plan was not updated, nor were any new interventions put in place. In this case, the care plan should have been revised to reflect that the resident shouldn’t be left alone in the courtyard.
The investigator of the citation asked the Director of Nursing (DON) for an incident report regarding the resident’s fall. The DON stated they did not have an incident report “because the resident did not get off the property, and it was not an elopement.”
While this incident was not an elopement, the facility failed to follow through on one vital procedure: updating the care plan. Care plans are essential because they document the appropriate ways to care for residents and keep them safe from harm. The DON confirmed the care plan wasn’t updated to prevent the resident from leaving the facility by himself.
In response to the citation, the facility finally updated the care plan. However, there were three months in between the time when the resident fell and the care plan was updated. In between those times, there were no instructions to the monitor the resident and ensure he didn’t leave by himself.
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