Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's care plan was reviewed and revised in a timely manner following a fall. The resident, who had a history of falls, a left hip fracture, and Alzheimer's disease, was admitted with a moderate risk for falls and required partial to moderate assistance with mobility and transfers. After an unwitnessed fall in the resident's room, there was no documented evidence that a new intervention—keeping the bed in the lowest position—was added to the care plan until three days later. The facility's policy required staff and practitioners to begin identifying possible causes and interventions within 24 hours of a fall, but this was not followed in this instance. Interviews with facility staff, including the DON and the primary physician, confirmed that the care plan intervention was not documented or implemented in a timely manner after the fall. The resident experienced another unwitnessed fall before the intervention was added to the care plan. Although staff reported performing routine hourly rounding, this was not documented in the care plan or care guides. The deficiency was cited under 10 NYCRR 415.11 (c)(2)(i-iii) for failure to update the care plan promptly to reflect new interventions after a fall.