Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised following a fall, as required by facility policy and procedure. A resident with a history of Type 2 Diabetes, Paroxysmal Atrial Fibrillation, anemia, and difficulty walking experienced an unwitnessed fall when attempting to stand from a wheelchair, which slid back. This was the resident's third fall in the facility. The resident reported the incident during an interview, stating that no injury was sustained. Review of the care plan and progress notes revealed that the post-fall assessment and care plan update were not entered into the electronic health record until approximately 36 hours after the fall occurred. Both the DON and DSD acknowledged that the care plan should have been updated on the day of the event, in accordance with facility policy, which requires care plans to be revised to reflect changes in interventions after a fall. The delay in updating the care plan was confirmed during interviews and record reviews.