Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following two separate falls, one of which resulted in a major injury. Despite the resident's history of Alzheimer's disease, diabetes, lumbosacral disc degeneration, and atherosclerotic heart disease, and a recent assessment indicating severely impaired cognition and a fall with major injury, the care plan was not updated to reflect the two recent falls. The care plan, last revised prior to the incidents, did not include new interventions or revisions after the falls occurred. Interviews with facility staff, including the Interim MDS Coordinator and the DON, confirmed that the care plan was not updated after the falls, even though facility policy and staff statements indicated that care plans should be revised following such events. The staff noted that all standard fall risk interventions were already in place and expressed uncertainty about what additional interventions could be added. The facility did not have an acute care plan policy, and the lack of timely care plan updates after significant changes in the resident's condition constituted the deficiency.