Failure to Revise and Date Fall-Related Care Plan Interventions After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise and properly date a comprehensive care plan after multiple falls experienced by a resident. The facility’s policy, dated 10/2016, requires an individualized, person-centered comprehensive care plan with measurable objectives and timetables, and specifies that assessments are ongoing and care plans are revised as resident conditions change. For one resident admitted in late August 2024 with dementia and a BIMS score of 00 indicating severely impaired cognition, the care plan contained a fall-related focus listing multiple fall dates from November 2024 through February 2026. However, the interventions on the care plan were not dated to show when they were implemented or revised, and there was no documentation that the care plan had been updated with new or individualized interventions following each fall. Record review of fall investigations showed that the resident sustained falls on several specific dates in December 2025 and February 2026. During interviews, the LPN/MDS Coordinator stated that care plans are required to be individualized and updated when there is a change in condition, including after falls, and that interventions should be clearly documented and dated to reflect when they were implemented. She confirmed that the resident’s fall interventions were not dated and that the care plan did not reflect additional or updated interventions after subsequent falls, making it difficult to determine when interventions were implemented or whether the care plan had been revised. The DON similarly confirmed that care plans are expected to be individualized and updated after falls, with dated interventions, and acknowledged that the resident’s care plan did not show additional or revised interventions with appropriate dates following the multiple fall incidents, which was inconsistent with facility expectations and policy.
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