Failure to Update Care Plan After Change in Resident's Fall Prevention Intervention
Penalty
No penalty information released
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 review and revise the comprehensive care plan for a resident following a change in care and services. The resident, who had diagnoses including dementia, repeated falls, need for assistance with personal care, and hypertension, had a care plan intervention for a pressure sensor pad alarm to be used at all times while in bed. However, the resident's physician orders did not include the pressure sensor pad alarm, and documentation showed that the use of the alarm was discontinued on 4/10/25. Despite this change, the care plan was not updated to reflect the discontinuation of the intervention. Facility leadership confirmed that the care plan was not reviewed or revised to match the resident's current care and services.