Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect the resident's history of falls. Specifically, after a resident experienced a fall, the facility's five-day follow-up report noted that fall precautions were in place and that the resident's bed would be placed against the wall to prevent further falls. However, a review of the resident's current care plan showed there was no focus statement, goals, or interventions related to being at risk for falls or a history of falls. The care plan had previously included a focus on fall risk, but this was resolved and removed several months prior, and no new interventions or goals were added after the most recent fall. This deficiency was confirmed during an interview with the Corporate Resource Nurse, who acknowledged that the care plan did not reflect the resident's fall history.