Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident following a fall incident. The resident, who had a history of Parkinson's disease, encephalopathy, unsteadiness on feet, lack of coordination, and previous falls, was admitted with these diagnoses and was identified as being at risk for falls. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required varying levels of assistance with activities of daily living, but had not experienced any falls since admission until the incident in question. On the date of the incident, the resident experienced a fall and was found sitting on the floor holding onto his walker. The assessment following the fall noted no injuries, and the physician was notified, resulting in an order for an x-ray. Despite this event, a review of the resident's care plan revealed that it had not been updated or revised to reflect the fall or to include any new interventions. The last revision to the care plan had occurred several months prior to the fall. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plan should have been updated after the fall to include additional interventions and ensure staff were aware of the necessary care. The facility's policy also required care plans to be reviewed and updated after significant changes in a resident's condition, such as a fall. The failure to update the care plan after the resident's fall constituted the deficiency identified in the report.