Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan with new interventions following a fall incident involving a resident with severe cognitive impairment, acute and chronic respiratory failure with hypoxia, and depression. The resident, who was dependent for toileting, bed mobility, and transfers, experienced a fall from bed resulting in a head injury. Although a post-fall evaluation was conducted and interventions such as placing a fall mat and using a low bed were implemented, these changes were not promptly reflected in the resident's care plan. The fall mat was not added to the care plan until over a month later, and the low bed intervention was never documented in the care plan, contrary to facility policy requiring timely care plan updates after status changes.