Failure to Develop Individualized Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop an individualized care plan to address a resident's actual fall incident that occurred on 11/22/24. Review of the resident's medical record showed that the resident was found on the floor on the right side of the bed in a side-lying position. The resident's history and physical examination indicated that the resident lacked the capacity to understand and make decisions. Despite this incident, the resident's plan of care did not include a problem or intervention related to the fall. Interviews with facility staff, including an RN and the DON, confirmed that there was no care plan developed to address the resident's fall. The facility's policy on comprehensive care planning requires that the plan of care include measurable objectives and timeframes and describe the services to be provided to maintain the resident's highest practicable level of well-being. The DON acknowledged that it was the responsibility of the licensed nurse to update the care plan with each change of condition, which was not done in this case.