Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for one resident after a fall incident. According to the facility's policy, care plans are to be updated as residents' conditions change. Medical record review showed that the resident was found on the floor after a fall and was subsequently assessed as being at high risk for falls. However, the care plan continued to reflect only a moderate risk for falls and was not updated to indicate the increased risk following the incident. This deficiency was confirmed through interviews with both an LVN and the DON, who acknowledged that the care plan had not been revised to reflect the resident's high fall risk after the event. The failure to update the care plan as required was based on direct review of the resident's records, facility policy, and staff interviews, with no evidence that the care plan was revised to address the resident's changed condition after the fall.