Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the comprehensive, resident-centered care plan for one resident following significant changes in condition, specifically after two documented falls. The resident, who is cognitively impaired and has multiple complex diagnoses including heart failure, atrial fibrillation, chronic kidney disease, and a history of falls, was admitted with a high risk for further falls. Despite the occurrence of falls on two separate occasions, the care plan addressing fall prevention was not updated until several months after the incidents. Interviews with the Director of Nursing and the MDS/Care Plan Coordinator confirmed that the expectation is for care plans to be updated promptly after a fall with appropriate interventions. However, documentation showed that the fall care plan was not initiated until long after the falls had occurred, contrary to facility policy which requires ongoing assessment and timely revision of care plans when a resident's condition changes. This lapse was identified through record review and staff interviews, which revealed a lack of timely action in updating the care plan to address the resident's increased fall risk.