Failure to Update Care Plan After Significant Change and Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following significant changes in her condition, specifically after a fall and a subsequent physical therapy evaluation. The resident, an elderly female with severe cognitive impairment, osteoporosis, Alzheimer's disease, unsteadiness, muscle weakness, and a history of falls, experienced a fall on 07/20/2025. Despite a physical therapy evaluation on 07/30/2025 recommending a two-person assist for transfers, the care plan was not updated to reflect this change. The care plan continued to indicate a one-person assist, and staff were not educated on the new requirement. On 08/03/2025, the resident fell again while being assisted to the restroom by a CNA who did not use a gait belt and was unaware of the need for a two-person assist. The resident was unable to bear weight after the fall, exhibited changes in behavior and eating, and was later diagnosed with a hip fracture, requiring surgery. Multiple staff interviews revealed a lack of communication and documentation regarding the resident's change in transfer status and post-fall assessments. The care plan and MDS were not updated in a timely manner, and staff were not consistently informed of the resident's needs, leading to improper care and delayed recognition of injury. Facility policies required care plans to be updated with measurable objectives and timetables following significant changes in a resident's condition. However, the interdisciplinary team did not revise the care plan after the therapy evaluation or the fall, and there was a breakdown in communication between therapy, nursing, and direct care staff. The failure to update the care plan and educate staff on the resident's new transfer needs resulted in the resident not receiving care in accordance with her current condition, as required by facility policy and professional standards.