F0657

D

Failure to Update Care Plan After Multiple Falls

Minocqua, Wisconsin Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to revise a resident’s care plan to reflect current fall risk interventions following multiple falls. The resident was admitted after hospitalization for increased confusion and falls at home, had a BIMS score indicating moderately impaired cognition, and had an activated POA for decision-making. Initial assessments documented no elopement risk and a low fall risk, and the care plan identified increased risk for falls related to deconditioning, ataxia, recent fall, muscle weakness, and noncompliance with transfer assistance, with interventions such as keeping the call light within reach and therapy evaluation and treatment. Despite this, the resident experienced several falls, including a fall with major injury resulting in a fractured pelvis and subsequent falls in the room.

After each fall, new fall interventions were documented on eINTERACT forms and in progress notes, such as placing a “Call for Help” sign and removing the walker when the resident was in bed with the wheelchair at bedside, but these interventions were not incorporated into the resident’s care plan. Surveyor observations confirmed the presence of the “Call for Help” sign and the walker’s placement in the room, and staff interviews showed varying understandings of the resident’s fall interventions, including toileting after meals, use of a floor mat, and keeping the bed in the lowest position. The DON confirmed that fall interventions documented after each fall had not been added to the care plan and that nurses were responsible for updating the care plan after completing eINTERACT forms. The surveyor determined that the facility did not revise the resident’s care plan to reflect current interventions to reduce fall risk.