Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the Comprehensive Care Plan (CCP) to accurately reflect new fall interventions for a resident following a fall incident. According to the facility's Fall Prevention and Response Policy, the care plan should be updated with any new or revised fall interventions after a fall occurs. Record review showed that the resident, who had a history of falls and moderate cognitive impairment, experienced a fall on 5/7/2025, resulting in being sent to the emergency room. Despite this incident, no new fall interventions were identified or added to the resident's CCP. Further review of the resident's records indicated that the most recent fall intervention documented in the CCP was dated nearly a year prior to the incident, and the fall prevention focus had not been updated since before the fall. The Director of Nursing confirmed during an interview that the CCP lacked new fall interventions after the recent fall and acknowledged that updates should have been made in accordance with facility policy.