Failure to Update Care Plans After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that care plans for two residents with a history of repeated falls were reviewed and revised to reflect their current needs after each fall. For one resident with intact cognition and diagnoses including repeated falls, heart failure, and chronic kidney disease, the care plan was last updated in July 2024, despite multiple subsequent falls documented in the medical record and nursing progress notes. No new interventions were added to address these incidents. Similarly, another resident with moderately impaired cognition, repeated falls, weakness, and gait abnormalities had a care plan last revised in early March 2025, with no updates or new interventions following several additional falls. Interviews with staff revealed that the responsibility for updating care plans was unclear, with updates typically handled by the DON, RN, or designated LPNs, and not by charge nurses. The administrator confirmed that care plans were expected to be updated after falls but was unaware that this had not occurred for the two residents in question. Policy reviews showed that while the facility's policies required care plans to be updated with new interventions after changes or falls, they did not specify who was responsible or the frequency of updates. This lack of clarity contributed to the failure to update care plans after significant events.