Failure to Timely Update Care Plan with Fall Prevention Interventions
Penalty
Summary
The facility failed to update and revise the person-centered care plan in a timely manner with appropriate interventions for a resident with multiple complex medical conditions, including a history of falls and a recent hip fracture. The resident's care plan, last revised on 12/2/24, included interventions such as a parameter mattress, enabler bars, and ensuring the call light was within reach, but did not include the use of a fall mattress as an intervention. Documentation and observation revealed that a floor mattress was in use as of 8/12/25, but this intervention was not reflected in the resident's care plan. During observation, the fall mattress was found leaning against the resident's wheelchair rather than being positioned by the bed as required, and the resident reported not getting up for breakfast. Interviews with the DON confirmed that the fall mattress should have been in place due to the resident's history of falls and hip fracture. The DON also described the process for updating care plans and communicating changes, but the care plan was not revised to include the fall mattress intervention, despite changes in the resident's status and needs.