Failure to Update Care Plan After Fall Assessment
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident after a fall risk assessment was completed. The resident, an elderly female with multiple diagnoses including muscle wasting, dementia with agitation, anxiety disorder, gait abnormalities, and cachexia, was identified as high risk for falls. Despite a fall risk assessment indicating a high-risk score and an unwitnessed fall occurring in the resident's room while attempting to toilet herself, the care plan was not updated to reflect new interventions following the incident. The last documented update to the care plan was prior to the fall, and no new interventions were added after the assessment on the date of the fall. Interviews with nursing staff revealed that updates and interventions were communicated verbally and through 24-hour reports, rather than by reviewing or updating the care plan. Both the RN and CNA involved in the resident's care confirmed that they did not review care plans for updates, relying instead on verbal communication. The interim DON was unaware that the care plan had not been updated after the fall, and facility policy required that individual plans of care be implemented after each fall risk assessment.