Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure the timely review and revision of a resident's comprehensive, person-centered care plan following a fall incident. A resident with a history of acute respiratory failure, dementia, and hypertension, and identified as having a low to moderate fall risk, was found on the floor next to their bed. The care plan in place prior to the incident included general fall prevention interventions, but there was no documented evidence that it was updated after the fall event. Following the fall, the resident was evaluated by a physical therapist who recommended the use of a floor bed as an intervention. Although this recommendation was communicated to nursing staff and discussed in a morning meeting, there was no documentation that the care plan was revised to include the floor bed intervention. Additionally, there was no evidence in the records to confirm whether the floor bed was provided to the resident. The facility's policies require that care plans be revised as resident conditions change and that interventions be updated after a fall. However, the fall risk assessment completed after the incident did not accurately reflect the resident's fall history, and the care plan was not updated to address the new risk or recommended interventions. Interviews with staff confirmed that the omission was due to oversight and that the care plan should have been updated following the fall.