Failure to Address Fall Risk and Hip Protection in Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for one resident who had a history of hypertensive heart disease with heart failure, a recently replaced artificial hip joint following a cerebrovascular event, and depression. The resident was admitted for therapy following a hip fracture and required assistance with activities of daily living. Despite being cognitively intact, the resident experienced two falls since admission, as reported by his wife, who expressed concerns about the risk of re-injury to the recently replaced hip and requested the use of fall mats, which she had observed being used for other residents. Observations on multiple occasions confirmed that no fall mats were present at the resident's bedside. Interviews with facility staff, including an LPN and the Physical Therapy Director, revealed that while interventions to maintain resident safety were discussed in interdisciplinary meetings, the care plan did not include the use of fall mats as an intervention to reduce the risk of injury from falls. The deficiency was identified when the care plan review showed the omission of this intervention, despite the resident's history and the family's expressed concerns.