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F0689
E

Failure to Update Care Plans and Implement Post-Fall Interventions

Palm Harbor, Florida Survey Completed on 12-11-2025

Penalty

No penalty information released
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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 implement post-fall interventions to prevent future falls for four residents who were identified as being at risk for falls. In multiple instances, after residents experienced falls, there was no evidence that new or revised interventions were added to their care plans. For example, one resident with diagnoses including sarcopenia, atrial fibrillation, and syncope experienced two falls, but the care plan was not updated with new interventions after either event. The Director of Nursing (DON) confirmed that no new interventions were added following these incidents, despite facility policy requiring individualized care plan updates after falls. Another resident, who was severely cognitively impaired and had a history of falls, was found on the floor with a head injury. Review of her care plan and medical record revealed that no new interventions were added after her fall, and there was no documentation from a physician indicating that additional interventions were unnecessary. Similarly, a resident with moderate cognitive impairment and a history of falls suffered a fall resulting in a large bruise, but the care plan was not updated to address the incident or to add interventions to reduce future risk. The DON acknowledged that the care plan should have been updated but was not. A fourth resident, also with moderate cognitive impairment and multiple comorbidities, experienced several falls. Although the interdisciplinary team discussed adding new interventions after one of the falls, the care plan was not updated to reflect these changes. Facility policy requires that each resident have an individualized plan of care that is reviewed and modified as needed to include appropriate fall interventions. The failure to update care plans and implement new interventions after falls represents a deficiency in ensuring the environment is free from accident hazards and that adequate supervision and interventions are provided to prevent accidents.

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