Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a resident with dementia and a history of falls. Despite the resident experiencing two separate falls, the care plan was not updated to include new interventions after each incident. Documentation showed that after both falls, staff performed assessments and monitoring, but no additional fall prevention strategies were added to the care plan. The care plan continued with existing interventions without revision, even though the resident's risk for falls was clearly identified. Interviews with facility staff, including the MDS Coordinator, DON, and ADON, confirmed that the care plan was not revised following the falls, contrary to facility policy and expectations. The staff acknowledged that care plans should be updated after such events to ensure appropriate interventions are in place. Facility policies reviewed indicated that care plans should be revised upon a change in resident status, such as a fall, but this was not done for the resident in question.