Failure to Update Care Plan After Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was reviewed and revised in response to a significant change in a resident's condition. Specifically, after a resident with diagnoses including heart failure and anxiety fell from a mechanical lift during a transfer—resulting in a humerus fracture and visible swelling—the care plan was not updated to reflect new interventions or address the incident. The resident, who required dependent assistance for transfers and had no prior history of falls, was observed with a sling and swelling, and reported that the fall occurred when only one staff member assisted with the lift transfer, contrary to safe practices. Documentation review revealed that the care plan addressing falls had last been updated prior to the incident and did not include any new interventions following the fall and injury. Interviews with nursing staff and the Director of Nursing confirmed that the care plan was not revised after the event, despite facility policy requiring care plans to be updated as residents' conditions change. The lack of timely review and revision of the care plan following the fall constituted a deficiency in meeting regulatory requirements.