Failure to Individualize Care Plans and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. For one resident with muscle weakness and cognitive communication deficits, the care plan was not individualized after a witnessed fall. The care plan, revised after the fall, only included checking range of motion and reporting mental changes, but did not address the specific cause of the fall, such as sliding from the wheelchair. Additionally, there was no Interdisciplinary Team (IDT) meeting conducted to discuss safety interventions following the incident. For another resident with difficulty walking and low back pain, the facility did not conduct an accurate fall risk assessment after a fall, as the assessment did not reflect the incident or the resident's poor balance and medication use, which could increase fall risk. The resident was incorrectly assessed as medium risk instead of high risk. Furthermore, after a subsequent fall, recommendations from rehabilitation services to apply bed railings and cushion pads along the bedside were not implemented. There was also no care plan created to address the new fall risk factors. Observations confirmed that recommended safety interventions, such as bed railings and cushion pads, were not present in the resident's room. The facility's own policies required appropriate assessments and interventions to prevent and minimize falls, as well as IDT review and care plan updates, but these procedures were not followed for the residents involved.