Failure to Review and Revise Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for four residents following documented falls. For one resident, after a fall was observed and documented by nursing staff, there was no evidence that the care plan, which had been created months prior, was reviewed or updated to address the incident. Interviews with staff confirmed that care plans are expected to be updated after such events, but this was not done in these cases. Another resident experienced multiple falls, each documented in the clinical record, but the care plan remained unchanged after each event. Staff interviews reiterated the expectation that care plans should be updated after falls, but documentation did not support that this occurred. The facility's own policy requires care plans to be reviewed and revised after assessments and as needed to reflect changes in the resident's condition or response to care. Additional residents also experienced falls, with clinical records and fall investigations documenting the incidents and subsequent assessments, but without evidence of care plan review or revision. In each case, staff interviews confirmed the expectation for care plan updates following such events, and facility policies supported this requirement. Despite this, the care plans did not reflect the necessary reviews or changes after the falls, as confirmed by both documentation review and staff statements.