Failure to Update Care Plan After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to revise a resident's care plan in a timely manner following a fall. The resident, who had a history of traumatic brain hemorrhage, Schizophrenia, severely impaired cognition, and required extensive assistance for mobility and transfers, was identified as being at risk for falls. The care plan in place included interventions such as reminding the resident to use the call bell and to toilet promptly. However, after the resident experienced an unwitnessed fall, which was documented in an incident report and nursing note, no new interventions were added to the care plan to address the circumstances of the fall or to prevent recurrence. Interviews with facility staff, including the charge nurse and the Director of Nursing (DON), confirmed that the care plan was not updated after the incident, despite facility policies requiring care plan revisions when a resident's condition changes or when desired outcomes are not met. The DON was unable to provide documentation of any care plan update following the fall, and the charge nurse could not recall if any changes were made. The facility's Fall Prevention Policy and Comprehensive Care-Planning Policy both direct staff to implement and revise interventions as needed, but these procedures were not followed in this case.