Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update and revise the care plan for a resident following two separate falls. The resident, who was admitted with diagnoses including diabetes, dysphagia, lack of coordination, and an above-knee amputation, was assessed as having moderately impaired cognition and required significant assistance with activities of daily living. The resident experienced falls on two occasions, once in the smoking patio and once beside the bed, as documented in the Change of Condition and Post Fall Assessment records. Although the post-fall documentation indicated that the care plan was updated, review of the actual care plan and interviews with the registered nurse supervisor revealed that the care plan was not created or revised until several days after the falls occurred. Facility policy required that the care plan be reviewed and revised after a fall, with new interventions implemented as appropriate. However, the care plan addressing falls was not initiated or updated in a timely manner following the resident's incidents. This resulted in a failure to develop and implement new interventions to prevent future falls, as required by the facility's Fall Management Program policy.