Failure to Timely Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to timely revise the care plan for a resident identified as a known fall risk, who experienced two falls from bed on 3/20/2025 and 4/9/2025. Despite the resident's complex medical history, including dementia, hemiplegia, and severe cognitive impairment, the care plan was not updated promptly after each fall event. The care plan in place prior to the incidents had last been revised in 10/2023 and included general fall prevention interventions, but did not reflect the specific circumstances or new interventions following the actual falls. After the first fall on 3/20/2025, documentation showed the resident was found on the floor, but the care plan was not revised to address this incident. Following a second unwitnessed fall on 4/9/2025, which resulted in bruising to the resident's face, the care plan was again not updated until 4/25/2025. Interviews with the MDS nurse and DON confirmed that the care plan should have been revised immediately after each fall, in accordance with facility policy and standard care practices, but this did not occur. Facility policies required that the care plan be reviewed and revised after significant changes in condition, including post-fall events, and that new interventions be implemented as appropriate. The delay in revising the care plan meant that the resident did not receive updated, individualized interventions following each fall, resulting in a lack of appropriate care and services and contributing to recurrent falls and injury.