Failure to Revise Care Plan After Fall Investigation
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident following a fall incident, despite conducting an investigation and identifying new interventions. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including muscle wasting, atrophy, and unsteadiness, experienced a fall from her bed that resulted in a facial injury. The facility's investigation after the fall identified interventions such as lowering the bed, ensuring the call light was within reach, and using fall mats. However, these interventions were not incorporated into the resident's care plan. Observations conducted after the incident showed that while the bed was lowered and the call light was within reach, fall mats were not present as planned. A review of the resident's care plan revealed that it had not been updated to include the new interventions identified during the investigation, with the most recent updates predating the fall. Interviews with the DON confirmed that changes were made in practice, but the care plan was not revised to reflect these interventions.