Failure to Update Care Plan After Fall Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated as needed following a significant change in the resident's condition. The resident, who had a history of repeated falls, major depressive disorder, and anxiety, was admitted with left-sided weakness and was identified as being at risk for falls. The initial care plan directed staff to encourage the use of the call light and to keep the resident's room free of clutter and tripping hazards. However, after the resident fell out of bed and staff moved the bed against the wall as a fall intervention, this change was not documented or incorporated into the resident's care plan. The Director of Nursing and Registered Nurse Coordinator confirmed that the intervention of placing the bed against the wall was not included in the care plan, despite being implemented after the fall.