Failure to Develop Care Plans for Residents After Falls
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address specific injuries for two residents following unwitnessed falls. For one resident, who lacked capacity to make decisions, a laceration to the right temporal area was documented after an unwitnessed fall. Despite this change in condition, there was no care plan created to address the laceration prior to the resident's transfer to an acute care hospital. Both the RN and DON confirmed that a care plan should have been initiated but was not present in the medical record. Similarly, another resident, also lacking decision-making capacity, sustained a skin tear to the left forearm after an unwitnessed fall. The medical record review and staff interviews confirmed that no care plan was developed to address the skin tear. The LVN and DON both acknowledged that a care plan should have been initiated following the incident, but it was not completed. These findings were based on interviews, medical record reviews, and review of facility policies and procedures.