Failure to Review or Revise Care Plan After Resident Fall
Penalty
Summary
Facility staff failed to review or revise the comprehensive care plan for one resident following a fall incident. The resident, who had a diagnosis including dementia and was severely cognitively impaired as indicated by a low BIMS score, experienced a fall that was documented in both nursing notes and a fall investigation. The documentation showed that the resident was found on the floor, was alert and oriented, sustained no injuries, and appropriate notifications and protocols were followed at the time of the incident. Despite the fall and the facility's policy requiring care plan review and updating after significant changes in a resident's condition, there was no evidence that the comprehensive care plan was reviewed or revised following the incident. The MDS coordinator confirmed that although the care plan was reviewed, there was no documentation to support this, and the care plan itself did not reflect the fall event. The administrator and director of clinical services were made aware of these findings.