Failure to Update Fall Interventions After Multiple Resident Falls
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, generalized weakness, and a history of falls did not have new interventions implemented after experiencing multiple falls. The resident, who was at risk for falls due to lack of coordination and recent hospitalization, experienced at least three documented falls within a short period. Despite these incidents, the care plan was not updated with new interventions following the falls on 7/3/25 and 7/12/25. The existing care plan included general fall prevention measures such as therapy, use of gait belts, frequent safety checks, and encouragement to use the call light, but did not address the specific circumstances or patterns of the recent falls. Interviews with nursing staff and administration revealed inconsistent practices regarding the updating of care plans and communication of interventions. The DON and ADON indicated that interventions were not always updated after each fall, and that staff were often informed of required interventions verbally rather than through formal documentation. The care plan was reviewed only every 30 days, and there was no evidence of new interventions being added after the most recent falls, despite the resident's ongoing risk and repeated incidents.