Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident following a fall with injury, despite documentation and orders indicating that a new intervention—signage reminding the resident to use the call light for assistance—was to be implemented. The resident, who had diagnoses including syncope, lower back pain, head injury, dizziness, muscle weakness, and difficulty walking, experienced a fall resulting in fractures. The medical record showed that after the fall, both a fall assessment and progress notes specified the need for signage as a new intervention, and a physician's order was written to this effect. However, review of the resident's care plan revealed that it had not been updated with the new intervention since before the fall, and no additional interventions regarding signage were added. The Director of Nursing confirmed during interviews that the care plan was not revised to include the new intervention after the fall, and was unable to provide a copy of the fall investigation. Facility policy required that care plans be specific to each resident's needs, list all interventions, and be updated at least quarterly and within seven days of comprehensive assessments, but this was not followed in this instance.