Failure to Update Care Plan After Resident Fall With Injury
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s comprehensive care plan with fall-related interventions following a fall with injury. The resident was an older female admitted with diagnoses including dementia, diverticulosis of the intestine, and heart failure. An MDS dated 2/26/26 documented a BIMS score of 14, indicating she was cognitively intact and independent in all ADLs. Her care plan, dated 2/9/26, identified her as a fall risk but contained no entry for a fall incident on 2/6/26 and no fall interventions, as she had no previous falls documented. On 2/6/26, during shift change, a CNA heard the resident’s roommate express concern and found the resident on the floor by her bed, sitting on her buttocks and holding her lower right side. The nurse assessed the resident and noted redness to the right side of the waist, intact skin, no bruising, no head injury symptoms, equal and reactive pupils, equal and strong grips, and maintained active range of motion. The resident reported she had been trying to get something from her bedside table, lost her balance, and fell. She complained of pain/discomfort to the right side of her waist and was given PRN tramadol. The environment was documented as free of clutter, with proper footwear in use and the call light within reach but not utilized. Subsequent documentation showed that the resident later complained of continued abdominal discomfort, was evaluated, and was ultimately found to have a right posterior 11th rib fracture and was admitted to the hospital before returning to the facility. Interviews and investigation notes confirmed the fall circumstances, including the roommate’s account of hearing a noise and seeing the resident on the floor with her head near the nightstand and feet toward the wheelchair. On review of the electronic care plan, the DON stated that the fall with injury was not present in the care plan and acknowledged that the fall should have been added when the resident returned from the hospital. The facility’s care plan policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s needs, but the resident’s care plan was not updated to reflect the fall event and related interventions.
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