Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update the care plans for two residents following documented fall incidents. For one resident, a fall occurred on 2/21/25 at 4:30 p.m., but a review of the care plans showed that the last revision was dated 11/25/24, with no updates or new interventions documented after the fall. The Director of Nursing confirmed during an interview that the care plan was not updated following this incident. Facility policies require care plans to be reviewed and revised by the interdisciplinary team after significant changes in condition or incidents such as falls, but this was not followed. Similarly, another resident experienced a fall on 1/12/25 at around 7:40 a.m., but the care plan reviewed on 5/8/25 did not include any updates or interventions related to the fall. The Director of Nursing also confirmed that the care plan was not updated for this incident. The facility's policies and procedures specify that care plans should be modified as necessary after significant events, including falls, but there was no evidence of such revisions in these cases.