Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident following multiple falls, as required by policy and regulatory standards. Clinical record review showed that the resident, who had moderately impaired cognition and several diagnoses including hypertension, anemia, fibromyalgia, difficulty walking, unsteadiness, muscle weakness, and knee pain, experienced falls on multiple occasions. Incident reports documented falls in the resident's room, with immediate actions taken such as moving furniture and providing education to the resident. However, the care plan was not updated to reflect new interventions after falls on two specific dates, and the CNA Kardex was not revised to include these interventions for several fall events. Staff interviews confirmed that the care plan and Kardex were not updated after each fall, despite the facility's policy requiring ongoing assessment and revision of care plans as resident conditions change. The DON acknowledged the lack of updates, and both nursing and CNA staff reported relying on the Kardex for current care interventions. The deficiency was identified through clinical record review, staff interviews, and policy review, demonstrating a failure to ensure care plans were revised in response to changes in the resident's condition and fall history.