F0657

D

Failure to Update Care Plans After Falls and Behavioral Incidents

Austin, Texas Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to ensure comprehensive care plans were reviewed and revised by an interdisciplinary team after each assessment and after acute incidents. For one resident with Type 2 diabetes, Crohn’s disease, asthma, dementia, major depressive disorder, and hypertension, the quarterly MDS dated 2/26/26 showed moderately impaired cognition and a need for supervision when walking up to 50 feet. The resident’s care plan documented a prior fall on 11/25/25 but contained no additional falls. However, progress notes and the facility’s incident log showed the resident sustained a witnessed fall on 1/22/26 during a supervised smoke break when another resident pushed her while reaching for a cigarette butt, and this fall was not added to or reflected in the care plan.

A second resident, admitted with aphasia, memory deficit, cognitive social or emotional deficit, and cognitive communication deficit, had a comprehensive MDS dated 2/27/26 indicating intact cognition and documented physical and verbal behaviors toward others. The resident’s care plan identified a potential to demonstrate physical behaviors related to anger and poor impulse control, but there were no updates following an incident on 2/13/26. Progress notes and the incident log documented that staff had to intervene and separate this resident from another resident due to verbal/physical aggression on that date, yet the care plan was not revised to reflect this event. During interview, the DON acknowledged that the care plans for both residents had not been updated after these incidents and stated that the MDS nurse was responsible for updating care plans after acute incidents, and that care plans are expected to be reviewed and revised when new problems or goals are identified per facility policy.