Failure to Update Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan did not reflect the resident's history of falls, despite documented incidents on three separate occasions. The resident, an older woman with multiple diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, was noted to have no cognitive impairment and was independent with transfers. However, her care plan did not include any mention of falls, even though incident reports documented both witnessed and unwitnessed falls without injury. Interviews with facility staff, including LVNs, the MDS RN, the DON, and the ADM, confirmed that falls should have been included in the resident's care plan and that it is the responsibility of various staff members to update the care plan with such information. The facility's policy requires that care plans be individualized, comprehensive, and revised as the resident's condition changes, incorporating measurable objectives and timetables. Despite these requirements and the staff's understanding of the process, the care plan was not updated to reflect the resident's falls, resulting in a deficiency.