Failure to Timely Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure timely revision of a resident's care plan following a fall incident. Clinical documentation showed that a resident with diagnoses including muscle wasting, difficulty walking, atrophy, and muscle weakness was readmitted to the facility and subsequently experienced an unwitnessed fall. The resident complained of right femur pain the day after the fall and was later admitted to the hospital with a right femur fracture. Despite these events, the resident's fall care plan was not initiated until over two months after the incident, and specific interventions such as assistance out of bed and monitoring for toilet needs were not scheduled to begin until even later. An interview with the DON confirmed that the care plan was not updated in a timely manner after the fall, contrary to facility policy requiring prompt care plan revisions when a resident's condition changes.