Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident who was identified as high risk for falls and had a recent history of a right femur fracture and generalized muscle weakness. The resident experienced a fall while attempting to reach his wheelchair to go to the bathroom, resulting in a skin tear on the back of the head and pain in the right hip. The incident occurred when the resident's call light was not activated, and he was found on the floor with his head slightly under the bed. The resident was assessed by the supervising nurse and subsequently transported to the hospital per physician's order, returning the same day. Despite the fall and the implementation of new interventions such as reiterating the use of the call light, lowering the bed, and using fall mats, there was no documentation in the resident's record reflecting these interventions upon return from the hospital. The Interim Director of Nursing confirmed that the care plan was not updated to reflect the fall or the new interventions. Facility policy requires staff and physicians to identify and document interventions to prevent subsequent falls and monitor the resident's response, but this was not completed in this case.