Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise and reassess the care plan for a resident following two separate fall incidents. The resident, who had a documented risk for falls and a care plan addressing this risk, experienced falls on two occasions, resulting in new skin tears during one of the incidents. Despite these events, the care plan was not updated to reflect the resident's current status or to reassess the effectiveness of existing interventions, as required by facility policy and federal regulations. Interviews with registered nurses and the Director of Nursing confirmed that the care plan was not revised after the falls, and that it should have been updated to guide staff in providing appropriate care. The facility's policies also require documentation and care plan updates following such incidents, but these actions were not taken in this case.
Plan Of Correction
F0657 - Care Plan Timing and Revision Immediate Corrective Action: On 09/25/2025 and 09/26/2025, a fall care plan was developed and updated for Resident #08. Residents Affected: On 09/25/2025, the RN Supervisor reviewed all residents with falls to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 17th, 2025, on the process for developing, reviewing, and updating care plans for falls. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and recent falls during IDT meetings. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025