Failure to Care Plan for Resident's Fall Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of falls. Record review showed that the resident, an elderly female with diagnoses including muscle weakness, lack of coordination, and dizziness, had an unwitnessed fall that was documented in the facility's incident report and progress notes. Despite this incident and the resident's high risk for falls, her quarterly care plan did not include any interventions or objectives related to fall prevention. The resident's MDS assessment indicated moderate cognitive impairment and a need for extensive assistance with activities of daily living. Interviews with facility staff, including the ADON and MDS nurse, confirmed that the resident should have been care planned for falls following the incident, but this was not done. Both staff members acknowledged their responsibility, along with the DON, for ensuring care plans were updated to reflect the resident's fall risk. The facility's policy requires an interdisciplinary approach to care planning based on MDS triggers and care area assessments, but this process was not followed in this case.