Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update comprehensive care plans for three residents following fall incidents, as required by policy and regulation. For one resident, after a fall occurred during peri-care when a CNA inadvertently overturned the resident's leg, the care plan was not updated to include the use of an assistive device in bed, despite this intervention being noted in the incident report. The resident's risk for falls care plan did not reflect the most recent fall or the new intervention. Another resident experienced a fall when attempting to get into bed independently after a CNA left to retrieve supplies. The care plan was not updated to include the fall or the preventive interventions implemented after the incident until the survey entrance date. A third resident, who had a pressure ulcer and was visually impaired, rolled off the bed, prompting the addition of bed rails, a bed alarm, and floor mats as immediate interventions. However, the care plan did not reflect the most recent fall or the addition of floor mats. These omissions occurred despite facility policy requiring that fall interventions be added to the care plan and revised as necessary.