Resident and Family Not Included in Post-Fall Care Planning
Penalty
Summary
The facility failed to involve a resident and/or their responsible party in the Interdisciplinary Team (IDT) conference following a fall incident. The resident, who had diagnoses including hypoglycemia and type 2 diabetes mellitus, was cognitively intact according to the Minimum Data Set (MDS) and required varying levels of assistance with daily activities. After the resident experienced a fall in front of the bathroom door, the IDT meeting was conducted with participation from nursing, rehabilitation, dietary, and activities staff, but without the involvement of the resident or their family. Interviews with facility staff, including a registered nurse and the Director of Nursing (DON), confirmed that the resident or family should have been included in the care conference. Review of facility policy also indicated that care plans are to be developed collaboratively with the resident and the IDT team. The omission of the resident and/or responsible party from the care planning process after the fall constituted a deficiency in person-centered care planning.