Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect post-fall needs. A resident with multiple diagnoses, including a broken leg, muscle weakness, and dementia, experienced an unwitnessed fall from bed. Following the incident, a fall assessment and interdisciplinary review were completed, and interventions such as a fall mat and keeping the bed in the lowest position were implemented. However, although the fall mat was observed in use and was identified as an intervention in the fall assessment, it was not documented in the resident's care plan. Staff interviews confirmed that the fall mat, while present in the resident's room, was not included in the care plan as required. The care plan did include other fall risk precautions, such as keeping the door open, locking bed brakes, and ensuring the resident was out of the room when in a wheelchair, but failed to reflect the addition of the fall mat. This omission indicated that the care plan was not properly updated to address the resident's post-fall needs.