Failure to Update Fall Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the fall care plan for a resident who had a history of falls and multiple medical conditions, including abnormal gait, generalized muscle weakness, dorsalgia, and a previous lumbar vertebra fracture. The resident experienced at least two falls during their stay, as documented in nursing progress notes. After one fall, the resident reported sliding from a chair due to a cushion, resulting in a bruise, and later complained of severe back pain, which led to an emergency room visit and diagnosis of a lumbar spine fracture. Despite these incidents, there was no documentation that the fall care plan was updated to reflect new interventions following the falls. Interviews with the DON and ADON confirmed that the care plan was not revised after each fall, and that standard interventions such as moving the resident closer to the nurse's station or providing non-skid socks were not documented as added to the care plan. The facility's policy requires the care plan to be updated within seven days of the comprehensive assessment and after significant changes, but this was not followed in the resident's case. The lack of timely updates to the care plan was acknowledged by facility leadership during the survey.