Failure to Update Care Plan After Resident Fall with Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following a significant fall event. The resident, an elderly male with multiple diagnoses including diabetes, muscle weakness, lack of coordination, cognitive communication deficit, unsteadiness, and a history of falls, experienced an unwitnessed fall from his bed resulting in a head laceration. Despite the incident, there was no review or revision of his care plan to address the new fall and necessary interventions. Prior to the fall, the resident's care plan identified him as being at risk for falls due to impaired mobility and muscle weakness, with interventions such as ensuring a safe environment and keeping the call light and personal items within reach. However, after the fall, which occurred when the bed was found in a high position and the resident was discovered face down on the floor with a head injury, the care plan was not updated to reflect the incident or to add new interventions. Staff interviews confirmed that the resident frequently used the bed remote to raise his bed, and staff would lower it during rounds, but this risk was not addressed in the care plan. The facility's own policy required care plan review and revision upon a change in resident status, such as a fall with injury. Despite this, documentation and staff interviews revealed that the care plan was not reviewed or revised after the incident, and the process for updating care plans following such events was not followed. This omission was acknowledged by facility leadership during interviews.