Failure to Develop and Implement Timely Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the fall risk of a resident who had multiple medical conditions, including a history of skull fracture, muscle weakness, gait and mobility abnormalities, diabetes, cognitive communication deficit, and several neurological disorders. Upon admission, the resident was assessed as having moderately impaired cognition and was identified as a fall risk, with behaviors such as standing up without staff supervision. Despite these assessments, no fall risk care plan or effective interventions were put in place prior to the resident's first fall. The resident experienced eight falls over a period of less than a month, with incidents occurring in various locations such as the bed, wheelchair, dining room, and near the nurses' station. Staff interviews revealed that the resident was confused, impulsive, and unable to safely stand without assistance, yet continued to attempt to do so. Although the resident was placed on frequent checks, these interventions were not documented in the care plan, and more intensive supervision, such as 1:1 monitoring, was not implemented. Staff acknowledged that the resident's need for supervision and specific fall prevention strategies were not addressed in the care plan until after several falls had already occurred. Record reviews and staff interviews confirmed that the care plan lacked fall prevention interventions until well after the resident's risk had been established and multiple falls had taken place. The facility's own policies required the development of a comprehensive, person-centered care plan with measurable objectives and timely interventions based on resident assessments. However, the care plan for this resident was not initiated on admission, and the necessary interventions to address the resident's high fall risk and supervision needs were not included or implemented in a timely manner.