Failure to Develop Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a baseline fall care plan for a resident who was admitted with multiple diagnoses, including type 2 diabetes mellitus, end stage renal disease, muscle weakness, and osteoarthritis. Upon admission, the resident was assessed as high risk for falls, as indicated by a fall risk assessment score of 15. Despite this high risk status and the resident experiencing several falls while in the facility, there was no care plan in place to address fall risk in the resident's clinical record. During an interview, the Assistant Director of Nursing (ADON) confirmed that there was no care plan to address the resident's fall risk and acknowledged that a separate care plan for falls should have been present. The facility's own policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes to meet each resident's identified needs, including those related to fall risk.