Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to update and revise care plans for multiple residents after they experienced falls, as required by both facility policy and regulatory standards. For example, one resident with a history of repeated falls, cognitive impairment, and physical limitations experienced several falls on specific dates, but her fall risk care plan was not updated after at least two of these incidents. Another resident, who was severely cognitively impaired and required assistance for transfers, also experienced multiple falls, yet his care plan was not revised following at least two of these events. In one instance, it was documented that the resident was wearing inappropriate footwear at the time of a fall, and a family grievance noted that required alarms were not consistently in place, despite being care planned interventions. A third resident, who was cognitively intact but required supervision for transfers and used a wheelchair, reported that staff did not provide assistance to prevent falls and that she often had to manage on her own. The care plan for this resident included interventions to prevent her from being left unattended, but these were not consistently followed. Additionally, a fourth resident with a history of hip fracture and Alzheimer's disease fell after losing balance while leaving the bathroom, and although recommendations were made for reeducation on call light use, the care plan was not updated with new interventions following the fall. Facility policies require that care plans be reviewed and revised by the interdisciplinary team after each assessment and after any fall, with input from caregivers and consideration of environmental hazards. Despite these requirements, the care plans for these residents were not consistently updated or revised after falls, and interventions were not always implemented or adjusted in response to incidents, as documented in interviews, observations, and record reviews.