F0689

D

Failure to Document Fall and Update Care Plan After Incident

Round Lake Beach, Illinois Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to document a resident’s fall and to update the resident’s care plan following that fall. Progress notes for the resident showed entries on one day indicating that the resident’s catheter had been dislodged and reinserted in the morning, and later that the catheter was removed during a recent fall, with another note stating the catheter was removed during a fall that evening. However, there was no documentation in the progress notes of the date, time, location, or any additional information related to the fall itself. The DON later confirmed that the nurse did not enter a note in the facility’s risk management system or any incident note in the electronic medical record about the fall, and that she was not aware the fall had occurred.

The resident’s care plan, dated prior to the fall, identified the resident as being at risk for falls related to hallucinations, antidepressant use, and behaviors such as intentionally sliding out of a wheelchair to the floor when up longer than desired. Despite this identified fall risk and the documented references to a fall in the catheter-related notes, the care plan was not reviewed or revised after the fall. The DON stated that care plans are to be updated after a fall and that she is responsible for updating them, but acknowledged that the resident’s care plan was not updated because she was unaware of the fall. The facility’s fall policy requires the nurse to complete risk management documentation for witnessed or unwitnessed falls and to complete an incident note under progress notes at the time of the incident, as well as to initiate interventions immediately based on the resident’s specific needs, which did not occur in this case.