Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update a comprehensive care plan for a resident after a fall that resulted in injury. According to the facility's policy, care plans must be updated with significant changes in a resident's condition, such as a fall. Record review showed that the resident had a history of falls, with the last documented fall and related interventions in the care plan occurring in January 2025. However, the resident experienced another fall in April 2025, which was witnessed by staff and resulted in the resident striking their left hip and shoulder. Despite this incident, the care plan was not updated to reflect the new fall or to include new goals or interventions for fall prevention. Interviews with staff revealed that the LPN responsible for updating care plans had been waiting for an incident report to provide new interventions, a process that had previously been managed by the former DON. Since the departure of the former DON, the system for communicating incident reports and interventions had lapsed, resulting in the April fall not being incorporated into the resident's care plan. The DON confirmed that the failure to update the care plan after the fall was contrary to facility procedures.