Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to update and revise care plans to reflect actual falls and implement new interventions for two residents following multiple fall incidents. For one resident, despite a documented unwitnessed fall from bed and noted impulsivity, the care plan did not include the fall event, the resident's impulsive behavior, or any new interventions post-fall. Staff interviews revealed uncertainty about the interventions in place and reliance on care plans for guidance, but the care plan remained outdated. For another resident, multiple falls were documented, including incidents where the resident was found on the floor or partially out of bed and wheelchair, with some resulting in injuries. Although the facility had a process for event reporting and a fall committee that met regularly, the resident's care plan was not updated with new interventions after each fall to address the root causes. The care plan only reflected interventions implemented shortly after admission, with no subsequent updates following the documented falls.