Failure to Update Fall Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a resident’s fall care plan after multiple falls, despite a policy requiring that interventions be reflected in the care plan and updated with revised or additional interventions. The resident, admitted with non-Alzheimer’s dementia and identified as at risk for falls due to weakness, impaired mobility, abnormal gait, and balance, initially had a care plan dated 08/20/25 with a post-fall intervention added on 11/02/25 for frequent checks while in their room. After that date, the care plan contained no additional interventions, even though the resident experienced numerous subsequent falls. Incident notes documented a witnessed fall without injury on 12/26/25 with interventions of non-slip socks and proper fitting shoes, an unwitnessed fall with a right elbow skin tear on 01/01/26 with no interventions documented, and another unwitnessed fall on 01/18/26 with no injuries or interventions documented. Further documentation showed the resident was seen in the emergency department on 01/20/26 for a fall resulting in a facial laceration repaired with tissue glue, facial bruising, and a knee injury, followed by monitoring for bruising and swelling to the right eye on 01/21/26. Additional unwitnessed falls occurred on 01/22/26, 01/24/26, and three times on 01/28/26, with no injuries or interventions documented for several of these events. On 01/29/26, the resident had two unwitnessed falls; one had non-slip socks as an intervention and the other resulted in a right elbow skin tear and bruising with an intervention to start Buspar for agitation. Observations showed the resident was unsteady, required hands-on assistance to walk, and was frequently ambulating in the halls with a CNA. Staff interviews revealed that CNAs and an LPN described various fall interventions (such as constant staff presence, snacks for distraction, frequent toileting, non-slip socks, and use of a specialized chair) and stated they relied on the electronic health record, room postings, charts, or verbal communication to know interventions. The DON stated care plans were to be updated after every fall but acknowledged that interventions after 11/02/25 were not on the care plan and that CNAs could not see progress notes where interventions were documented.
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