Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the comprehensive care plan with new interventions after each fall for one resident. Record review showed that the resident experienced two unwitnessed falls within a five-day period. Despite the facility's policy requiring the care plan to be updated by an interdisciplinary team after such incidents, the last update related to falls was completed over a month prior to the most recent falls, and no new interventions or goals were added following these events. Interviews with nursing staff and administrative personnel revealed that only the Director of Nursing Services (DNS) and the Minimum Data Set Coordinator (MDSC) were responsible for updating care plans. Both confirmed that the care plan for the resident in question was not updated on the same day or the day after the falls, as required by facility policy. The MDSC acknowledged that the care plan had not been revised until several days after the incidents, contrary to established procedures.