Failure to Update Care Plans After Significant Incidents
Penalty
Summary
The facility failed to review and revise care plans to reflect significant incidents or changes in condition for two residents. One resident, admitted with multiple diagnoses including chronic kidney disease, diabetes, morbid obesity, and dependence on renal dialysis, experienced a fall in her room and was sent to the emergency room for evaluation. Despite this incident, her care plan continued to state she was only "at risk" for falls and did not document the actual fall event or update interventions accordingly. The Director of Nursing stated that the incident was not considered a fall and therefore was not investigated or reported as such. Another resident, with diagnoses including dementia and a history of falls, had a care plan indicating risk for elopement and falls, with interventions for wandering and safety. However, after a documented fall, the care plan was not updated to reflect the incident or to include new interventions to prevent future falls. The facility's own policy requires updating care plans and developing fall intervention plans after such incidents, but this was not followed in these cases.