Failure to Revise Fall-Risk Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s fall-risk care plan after a documented fall. The resident was admitted with diagnoses including metabolic encephalopathy, dementia, and difficulty walking. An MDS assessment dated 7/8/2025 showed the resident was unable to make reasonable and consistent decisions, required partial to moderate assistance with ADLs such as transfers and repositioning, and was incontinent of bowel and bladder. A care plan dated 8/10/2025 identified the resident as at risk for falls due to incontinence, psychoactive drug use, and unawareness of safety needs, with goals for the resident to be free from falls and serious injury. Interventions included anticipating and meeting needs, prompt staff response to calls, and maintaining a safe environment with clear pathways, adequate lighting, and personal items and call light within reach. On 12/25/2025, a Change of Condition Evaluation documented that the resident had a fall and was found sitting on the lobby floor with blood on her face. A Change in Condition Progress Note dated 12/26/2025 recorded that the resident was found on the floor by the nursing station with a quarter-sized, actively bleeding cut on the forehead. Paramedics were called, and the resident was transferred to a general acute care hospital via 911 for further treatment. The resident’s emergency contact later stated that staff informed her of the fall incident but did not call her to attend a meeting to discuss care concerns and interventions after the fall. Record review showed no documentation that the IDT implemented a care conference with the resident’s emergency contact to discuss recommendations, changes, or updates to the fall-risk care plan after the fall. The resident’s fall-risk care plan contained no revisions or updates to include interventions following the 12/25/2025 fall. RN 1 stated that the resident had an unwitnessed fall at change of shift, that he instructed the CNA to perform frequent visual checks, and that he was unable to review and revise the fall-risk care plan or formulate a care plan for an actual fall, acknowledging that licensed nurses are responsible for updating and revising care plans. The Director of Rehab and the DON both confirmed that there was no documented IDT meeting and that the resident’s fall-risk care plan was not revised or updated after the fall, despite facility policies requiring development, implementation, and revision of comprehensive care plans and review and updating of care plans under the fall prevention program.
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