Failure to Update Fall Care Plan After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s fall care plan updated following multiple falls, as required by regulation and facility policy. The resident was admitted with diagnoses including a fractured right pubis, diabetes, obesity, and kidney failure, and required substantial assistance with ADLs such as showering, standing, and toileting, using a walker or wheelchair for mobility. The MDS identified moderate cognitive impairment and a fall in the month prior to admission. The initial care plan, dated 11/3/25, documented a fall risk score of 5 (low risk) and included general interventions such as encouraging slow transitions from lying to sitting and sitting to standing, keeping the call light within reach, allowing use of half upper side rails, and directing staff to provide first aid, assess for causes, remedy as needed, and report to the primary care physician in the event of a fall. Progress notes documented three separate falls: the resident was found sitting on the floor next to the bed early in the morning on one date, found on his knees in front of the commode with a skin tear to the left elbow on another date, and later found on the floor again, after which he experienced pain and inability to stand as usual, leading to an x-ray order and transfer to the emergency room where a re-fracture of the right pelvis was identified and the resident did not return. Despite these falls, the comprehensive care plan was not updated to include new, resident-specific fall interventions related to the incidents on 11/15/25 and 11/17/25. A mini care plan noted use of a low bed and an intervention that the resident should not be left on the commode alone, but the dates were unclear and these measures were not incorporated into the main care plan. The RN care plan coordinator confirmed that no new interventions were added to the care plan after the falls, which was inconsistent with the facility’s Fall Assessment and Management Policy requiring that interventions and safety measures be communicated to staff and added to the mini care plan immediately following a fall and that fall-reduction interventions be resident-specific and based on the fall.
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