Failure to Revise Care Plan After Resident Fall Incidents
Penalty
Summary
The facility failed to update the person-centered care plan for a resident after two fall incidents, as required by its policies and regulatory standards. The resident had diagnoses including dementia, muscle weakness, and abnormalities in gait and mobility. Interdisciplinary Team notes documented that the resident experienced two falls on 1/14/26. During an observation and interview, the resident was alert, verbally responsive, and sitting in a wheelchair in the hallway, able to state his name but unable to identify his current location or the reason for residing in the facility. When asked about the falls, the resident reported feeling sleepy, attempting to walk, and needing to use the bathroom at the time of the incidents. In interviews, LVN 1 stated that care plans are initiated when there is a change in condition such as a fall and that care plans are reviewed and updated after each fall, but also stated she had not received in-service training on care planning. LVN 2, upon reviewing the resident’s care plan, confirmed that it did not address the two fall incidents. LVN 2 also stated she had not received in-service training on care planning. The Administrator reported that the DON and DSD were responsible for providing in-services to licensed nurses, but they were not available for interview. Facility policies on person-centered plans of care and post-fall management required that care plans reflect current standards of practice, include interventions to manage risk factors, and be reviewed and revised by the IDT when changes in the resident’s care and treatment occur, including after falls, but this was not done for the resident following the two fall events.
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