Failure to Update Fall Risk Care Plan After Each Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan after each fall, as required by facility policy and staff expectations. The resident had diagnoses including hypertension, alcohol dependence, and osteoarthritis, and a BIMS score of 8 indicating moderately impaired cognition. Progress notes documented multiple unwitnessed falls during a two‑month period, specifically on 11/04/2025, 11/05/2025, 11/27/2025, 11/30/2025, 12/05/2025, and 12/07/2025. The comprehensive care plan, dated 01/21/2026, identified the resident as being at risk for falls and injury related to falls, with risk factors such as need for assistance with ADLs, possible medication side effects, chronic pain, and osteoarthritis. The care plan included dated interventions tied to several of the fall events, such as encouraging rest during fatigue, obtaining labs, resident education on using the call light and proper bed positioning, labs to rule out UTI, referral to therapy, and labs to rule out high ammonia levels. Despite these documented falls and the facility’s Fall Prevention Program and Restorative Nursing Program requirements that care plans address each fall and that interventions be changed with each fall as appropriate, the care plan was not updated following the fall that occurred on 11/30/2025. Interviews with the MDS Coordinator/LPN, the Restorative Director, and the DON confirmed that the facility’s expectation is that the care plan be updated with each fall, that each fall be treated as needing a new intervention, and that the IDT investigate to determine root cause and adjust interventions accordingly. When shown the care plan and the sequence of falls, these staff acknowledged that the care plan should have been updated to address the 11/30/2025 fall but was not, resulting in a failure to follow the facility’s own fall prevention and care planning guidelines.
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