Failure to Update Care Plan and Implement Fall Precautions After Multiple Falls
Penalty
Summary
The facility failed to implement fall precautions and update care plan interventions following multiple falls for a resident with significant risk factors. The resident had diagnoses including syncope, repeated falls, chronic kidney disease, and severe cognitive impairment. Despite a history of falls and specific care plan interventions in place, the care plan was not consistently updated with new interventions after each fall event, as required by facility policy and regulatory standards. Several incidents were documented where the resident experienced falls, including being found on the floor in another resident's room, in front of her wheelchair, and by her bed. After some of these falls, such as those on 12/21/25, 4/13/25, and 5/19/25, there was no evidence that new interventions were added to the care plan. In one instance, a new intervention (pommel cushion) was added after a fall, but this was not consistently done after subsequent incidents. Staff interviews confirmed that new interventions should be implemented after each fall, but this was not always carried out. Observations also revealed that some existing interventions were not properly implemented, such as the use of non-skid strips and signage to remind the resident to ask for assistance. The non-skid strips were smaller than intended, and the required signage was missing from the resident's room. Staff interviews corroborated these findings, indicating a lack of adherence to the care plan and facility policy regarding fall prevention and care plan updates.