Failure to Revise Care Plan for Fall Interventions
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to revise the care plan for a resident regarding fall interventions. Observation revealed that the resident was in a low bed with fall mats on the right side and the left side of the bed against the wall, while receiving 1:1 supervision as ordered. Orders were in place for 1:1 supervision and floor mats on the right side of the bed for both day and night shifts, but there were no orders for a low bed with a parameter mattress. The resident's care plan only included a low bed with a parameter mattress as a fall intervention, and did not document the use of floor mats, the bed against the wall, or 1:1 supervision. These discrepancies were confirmed by the DON and a corporate RN.