Failure to Update Care Plan After Resident Fall
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes addressing a resident’s fall that occurred in the facility. The resident was an elderly female with hypertension and dementia, with a BIMS score of 7 indicating severe cognitive impairment, initially admitted in mid-November and readmitted in late December. Record review showed that although the resident’s care plan, revised at the end of January, identified her as being at risk for falls related to impaired mobility and listed general fall-prevention interventions (such as anticipating needs, keeping the call light within reach, and educating resident/family/caregivers about safety and what to do if a fall occurs), it did not include the specific fall event that occurred on 12/25/25. Observation on 02/03/26 found the resident in bed in the lowest position with the call light within reach, and she did not respond to the surveyor’s questions about the facility’s care or services. Interviews with facility staff confirmed that the fall should have been incorporated into the resident’s care plan as a change of condition. The MDS nurse stated that a fall is considered a change of condition that must be added to and updated in the care plan, that care plans are individualized to inform staff how to provide care, and that ADONs are responsible for making acute changes while MDS nurses review care plans quarterly or as needed for significant changes. The DON similarly stated that the fall was a change of condition that should have been included in the care plan and that nursing staff are responsible for monitoring and updating care plans for acute changes, with MDS nursing reviewing care plans quarterly and monitoring daily. The Administrator stated that the care plan is intended to paint a picture of residents’ needs and provide information to all staff, and that care plans are reviewed quarterly by MDS nursing and updated immediately by nursing staff when there is a change of condition. The facility’s undated Comprehensive Care Planning policy stated that the facility will develop and implement a comprehensive care plan for each resident, consistent with resident rights, including measurable objectives and timeframes to meet identified needs, and that care plans will be reviewed and revised after admission, quarterly, annually, and/or with significant change MDS assessments and in response to current interventions.
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