Care Plan Not Updated to Reflect Fall Prevention Interventions
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to update and implement a care plan addressing communication needs for a resident identified as a fall risk with a diagnosis of anoxic brain damage. The resident was observed in bed with a fall mat placed on the floor, but the care plan, last updated on 2/5/25, did not include the use of a fall mat as an intervention. The care plan only specified placing the call light and personal items within reach when the resident was in bed or a bedside chair. There was no evidence that the care plan was revised to reflect the use of the fall mat, as required by facility policy, which states that care plans must be customized, communicated, and updated to reflect changing needs and responses to care.