Failure to Revise Fall Care Plan After Recurrent Fall
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s fall care plan after a subsequent fall, as required by facility policy and care planning standards. Interview with the Restorative Nurse established that she is responsible for entering fall-prevention interventions into residents’ care plans and that care plans should be updated to reflect each fall, with different interventions added when a resident experiences multiple falls. She stated that if a resident continues to fall, maintaining the same interventions indicates they are not effective and that not changing them puts residents at greater risk of falling. The Restorative Nurse acknowledged that she did not update the fall interventions in the resident’s care plan after the resident experienced another fall. Record review showed that the resident’s care plan, dated 10/15/2025, identified the resident as being at risk for falls related to confusion, gait/balance problems, incontinence, and a history of falls. The care plan listed multiple fall-prevention interventions, including anticipating and meeting needs, proper positioning in bed, ensuring the call light is within reach, use of bed bolsters, safety education, appropriate footwear, following the facility fall protocol, frequent monitoring, keeping items within reach, maintaining a clutter-free environment, keeping the bed in a low position, monitoring medication side effects, use of dycem in the wheelchair, provision of a floor mat, and use of hip protectors. Additional interventions for history of falls included a floor mat on the side of the bed, frequent checks, and a low bed. However, review of the care plan dated 11/09/2025 showed no updates or new interventions added after the resident’s fall on the specified date, despite the facility’s policy stating that when a significant change occurs in a resident’s condition, the MDS coordinator or designee is notified and the care plan is reviewed and updated.
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