Failure to Revise Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the care plans for two residents following changes in their conditions, specifically after each experienced unwitnessed falls. For one resident, the care plan was last revised prior to a documented fall, and no new fall intervention was added after the incident. The resident was assessed as moderately cognitively impaired and at risk for falls due to confusion, incontinence, and psychoactive drug use. Despite an incident report documenting a fall, the care plan did not reflect any updated interventions addressing this event. For the second resident, the care plan was also not updated after two separate unwitnessed falls. The resident was assessed as cognitively intact and considered low risk for falls, with risk factors including psychoactive medications and extrapyramidal symptoms. Incident reports documented two falls, but the care plan did not include any new interventions following these events. Interviews with staff and administration confirmed that care plans are expected to be updated after such incidents, but this was not completed due to competing assignments and oversight.