Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a care plan was reviewed and revised in a timely manner following a fall incident involving a resident. The resident, who had a history of respiratory failure, hemiplegia, and hemiparesis following a stroke, experienced a fall in their room after attempting to transfer from their wheelchair to bed. The incident was documented in the facility's incident report log, and the resident was able to communicate their needs. Despite the fall being reported, a review of the resident's care plan showed that no new interventions were created or initiated after the incident. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that the care plan was not updated within the expected timeframe following the fall. Both staff members acknowledged that interventions should have been added to the care plan shortly after the incident to address the resident's needs and prevent further falls.