Failure to Implement Baseline Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to implement a baseline care plan addressing fall risk for a resident with multiple diagnoses, including diabetes mellitus, a history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis. Upon admission, the resident's hospital records indicated osteoporosis and compression fractures, and the resident was placed on fall precautions. Despite this, the baseline care plan created did not document the resident's history of falls, nor did it include the resident's signature. Additionally, the care plan did not address the resident's high risk for falls, as identified in fall risk reviews conducted on two separate occasions. During interviews and record reviews, it was confirmed that the Director of Nursing presented all care plans for the resident, but none included a plan for high fall risk. The facility's policy required the admitting nurse to initiate a baseline care plan assessment upon admission to identify potential problems and implement appropriate interventions, with further review and revision by the interdisciplinary team within 72 hours. However, this process was not followed for the resident in question, resulting in the omission of necessary fall risk interventions in the baseline care plan.