Failure to Update Care Plan After Fall and Implementation of Tab Alarm
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a resident's care plan was revised and updated as needed following significant events. A resident with Alzheimer's disease and apraxia experienced two unwitnessed falls, one of which resulted in a recommendation to implement a tab alarm for safety. Documentation showed that the tab alarm was in use after the second fall. However, review of the resident's care plan revealed that it did not include the use of a tab alarm, only instructions to leave the call button within reach. The Director of Nursing confirmed that the care plan should have been updated to reflect the addition of the tab alarm after it was implemented.