F0657

D

Failure to Update Care Plans After Specialist Visits and Unwitnessed Fall

Washington, District Of Columbia Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to update and revise comprehensive care plans based on residents’ changing needs and clinical events. For one resident with anemia, polyneuropathy, atherosclerotic heart disease, peripheral vascular disease, HIV, presbyopia, and dry eye syndrome, the care plan did not reflect ophthalmology follow-up visits or recommendations. The resident reported wanting to see an ophthalmologist, and record review showed the resident had been seen by an ophthalmologist multiple times since admission, including a visit with a recommendation for a one-year follow-up. However, the care plan contained no updated documentation that these follow-up visits occurred, and progress notes lacked evidence that the recommended ophthalmology follow-up was completed.

For another resident with leukemia, dementia, asthma, and respiratory failure, who required substantial to maximal assistance for mobility and used a wheelchair, the facility did not update the care plan after an unwitnessed fall with injury. Nursing documentation described the resident being found on the floor in her room with a right elbow skin tear and complaints of right-sided pain, followed by orders for an X-ray and transfer to the ER. Hospital records documented a right femoral neck fracture and right ulnar fracture, with subsequent surgical procedures. Although a care plan was initiated for the right elbow skin tear and later for the right femur fracture with surgical site and staples, the care plan was not updated to include that the resident had an unwitnessed fall in her room. The facility’s own documentation policy requires complete, accurate, and timely documentation of residents’ experiences, but the care plan did not reflect this fall event.