Failure to Update Care Plans Following Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated and revised following actual falls for two out of four residents reviewed for falls. For one resident with severe cognitive impairment, dementia, and total dependence for mobility and transfers, the care plan was not updated to reflect a fall from a Hoyer lift during a transfer by two CNAs. Although the care plan was later updated with staff education and a physical therapy evaluation, there was no documented evidence that the actual fall event was incorporated into the fall risk care plan as required by facility policy. Another resident, who was cognitively intact but had muscle weakness, ambulatory dysfunction, and required assistance with mobility, experienced an unwitnessed fall in their room resulting in a laceration and skin tears. The care plan for this resident, which identified fall risk due to their physical limitations, was not updated to include the details of the fall incident. Interviews with staff revealed a lack of awareness and inconsistent practices regarding the requirement to update care plans immediately after a fall, with some staff relying on progress notes rather than revising the care plan itself.