Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update the care plans for three residents following multiple documented falls. Each resident experienced one or more falls, as evidenced by incident reports and nurse's notes, but their care plans were not updated to reflect new or revised fall prevention interventions after these incidents. This lack of timely care plan revision was confirmed through record review and staff interviews. One resident with severe cognitive impairment and diagnoses including repeated falls, a progressive neurological condition, and Parkinson's Disease experienced three separate falls. Despite these incidents, the resident's care plan was not revised to address the specific circumstances or to implement new interventions after each fall. Staff interviews confirmed that the care plan remained unchanged prior to the survey. Another resident with Alzheimer's Disease and a history of falls, as well as a third resident with multiple fractures and neuropathy, also experienced falls that were not followed by updates to their respective care plans. In each case, staff acknowledged during interviews that the care plans should have been revised to reflect the falls and to include appropriate interventions, but this was not done prior to the survey team's review.