Failure to Develop Baseline Fall Risk Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan to address fall risk within 48 hours of admission for two residents. Both residents were admitted with conditions that included unsteadiness on their feet and a history of repeated falls, as documented in their admission records. Fall risk assessments conducted upon admission identified both residents as high risk for falls, with scores of 22 and 26, respectively. Despite these findings, there was no evidence in the clinical records that a baseline care plan for fall risk was created for either resident within the required timeframe. Interviews with facility staff, including a licensed nurse and the Director of Nursing (DON), confirmed that the purpose of the admission fall risk assessment is to identify high-risk residents and develop interventions to prevent falls. The DON acknowledged that interventions should have been in place immediately and that the absence of a baseline care plan meant that necessary fall prevention measures were not communicated to the care team. A review of facility policy further indicated that a baseline plan of care must be developed within 48 hours of admission to address immediate health and safety needs.