Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to update and revise care plans for multiple residents following fall events, as required by policy and regulatory standards. For four residents, care plans were not updated to reflect new interventions or to address the root causes of falls, even after incidents that resulted in injuries. In several cases, fall safety event forms were not completed, and there was no documentation of root cause analyses or evaluation of existing interventions. For example, one resident experienced a fall resulting in a rib fracture while on anticoagulant medication, but the care plan was not updated to reflect this risk or to include new interventions. Another resident had an unwitnessed fall, but the care plan was not reviewed or revised, and the event remained open without a root cause analysis for over a month. Additionally, two other residents experienced multiple falls with injuries within a short time frame, yet their care plans showed no updates or new interventions in response to these incidents. Staff interviews revealed confusion regarding responsibility for updating care plans after falls, and there was a lack of clear communication about care plan changes to direct care staff. The facility's own fall prevention policy required care plan review and updates after any fall, but this process was not consistently followed, as evidenced by the lack of documentation and intervention updates in the residents' records.