Failure to Update Care Plan After Resident Fall with Injury
Penalty
Summary
A resident with diagnoses including dementia, Alzheimer's disease, and diabetes experienced a fall resulting in a left wrist fracture. Despite the fall and subsequent injury, the resident's care plan was not updated to reflect the incident or to include interventions aimed at preventing future falls. The facility's policies require that care plans be revised following significant changes in a resident's condition, such as a fall with injury, and that interventions be implemented to address new risks. However, the care plan for this resident, initiated prior to the fall, did not document the fall or any fall prevention strategies. Staff interviews and record reviews confirmed that the omission occurred, with nursing staff and management acknowledging that the care plan update was missed. The facility's own protocols specify that care plans should be reviewed and revised as residents' conditions change, but this process was not followed after the resident's fall. Additionally, staff education on updating care plans after such incidents had not been completed at the time of the survey.