Failure to Initiate Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a fall risk care plan for a resident with multiple risk factors, including hemiplegia, morbid obesity, muscle weakness, dementia, and a history of falls. Upon admission, the resident was identified as high risk for falls due to recent hospitalization, incontinence, multiple diagnoses, and medication use. Despite this, no fall risk care plan was initiated at the time of admission or prior to a significant fall event. The resident experienced an unwitnessed fall, resulting in a closed rib fracture and significant pain. Documentation shows that the resident was found on the floor after calling for help, and subsequently required transfer to an acute care hospital for evaluation and treatment. The resident continued to experience pain after returning to the facility, necessitating stronger pain management interventions. Interviews with nursing staff and the DON confirmed that a fall risk care plan was not in place prior to the fall, despite facility policy requiring such plans to be developed upon admission for residents identified as high risk. The care plan was only initiated after the fall occurred, contrary to established procedures and expectations for resident safety.