Failure to Update Care Plans After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were periodically reviewed and revised by a team of qualified persons after each assessment and after falls, as required. For one resident with Alzheimer’s disease, dementia, muscle weakness, reduced mobility, joint stiffness, and bone density disorder, the comprehensive care plan identified fall risk and included multiple fall-related interventions with various initiation and revision dates. However, facility incident/accident reports showed this resident sustained an unwitnessed fall on 11/27/2025 that was not reflected or updated in the resident’s care plan. A second resident, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contractures, muscle weakness, lack of coordination, dementia, and mood disorder, also had a care plan identifying fall risk related to CVA, dementia, and right-sided weakness. The care plan contained general fall-prevention interventions and showed an initial date and a revision date. Review of the facility’s incident/accident reports revealed that this resident experienced three witnessed falls on 11/14/2025, 12/16/2025, and 12/30/2025, none of which were reflected or updated in the resident’s care plan. In interviews, the MDS/RN stated that, per direction from a corporate consultant, care plans were no longer updated with dated interventions after each fall, and that staff instead relied on incident reports, progress notes, post-fall evaluations, neuro check forms, the 24-hour report, and previous progress notes for information on interventions and updates. The MDS/RN reported that care plan reviews were done quarterly, annually, and with significant changes in condition, and that dated interventions were not routinely added after each fall, especially when there was no injury or significant change. The DON stated that staff learned of changes to interventions through in-services and incident reports and that care plans were updated when incidents occurred or as needed, but acknowledged, after hearing the facility’s Fall Management System policy, that each fall should be documented, reviewed, and reflected with dates and interventions in the care plan.
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