Failure to Revise Care Plan for Fall Prevention
Penalty
Summary
The facility failed to timely revise the care plan with specific fall-prevention interventions for a cognitively impaired resident who required staff assistance. The resident, who had a history of repeated falls and was diagnosed with dementia, psychosis, anxiety disorder, major depressive disorder, and other conditions, experienced a fall on March 15, 2025, while being transported in a wheelchair without leg rests. This incident resulted in a bruise on the resident's forehead and face, and the resident was subsequently transported to the hospital for evaluation. Despite the resident's history of falls, the care plan was not updated with specific interventions to prevent future incidents, and no root cause analysis was conducted after each fall to address contributing factors. The Acting Director of Nursing confirmed that the fall on March 15, 2025, did not prompt a care plan revision, and no targeted prevention measures were implemented, highlighting a deficiency in the facility's response to the resident's fall risk.