Failure to Update Care Plan With Required Dining Room Supervision After Fall
Penalty
Summary
The facility failed to ensure a resident’s fall-prevention intervention was timely incorporated into the care plan, resulting in the resident being left unsupervised in the dining room and experiencing repeat falls. The resident was admitted with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking. On 12/1/25, an IDT fall investigation documented that the resident had fallen from her wheelchair while unattended in the dining room and concluded that she was to be always supervised while in the dining room to avoid future falls. However, this supervision intervention was not added to the resident’s care plan at that time. On 1/23/26, the resident again fell from her wheelchair when a staff member left her unsupervised in the dining room, as documented in a 1/26/26 fall investigation report. The care plan was not revised to include constant supervision in the dining room until 1/27/26, and the DON confirmed that the supervision intervention should have been added in December 2025 but was not. The deficiency centers on the facility’s failure to update the resident’s care plan after the first documented fall and identified intervention, leaving staff without a formalized directive to provide constant supervision in the dining room between early December 2025 and late January 2026. During an interview on 3/4/26, the DON acknowledged that the care plan related to staff supervision for this resident was not added until 1/27/26, despite the IDT’s earlier determination on 12/1/25. When asked if the fall on 1/23/26 could have been prevented had the care plan been updated in December 2025, the DON declined to answer.
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