Failure to Individualize Care Plan for High-Risk Resident Results in Fall and Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan that addressed all of a resident's needs and preferences, specifically regarding supervision and assistance during showering. The resident, a female with legal blindness, severe osteoarthritis, and a history of falls, was admitted with declining functional abilities and was assessed as high risk for falls. Despite these risk factors, her care plan did not include interventions for her preference to be left alone in the shower room, nor did it address the need for assistance or supervision during showering. On the day of the incident, the resident was left alone in the shower room by a CNA, who waited outside the bathroom. Within minutes, the resident lost her balance while attempting to put on her robe after showering, resulting in a fall. The CNA and other staff responded after hearing a yell and a loud noise, finding the resident on the bathroom floor. The resident sustained significant injuries, including a fractured breastbone, thoracic spine fractures, a scalp bruise, and required a two-day hospital stay. Interviews with staff confirmed that the resident's legal blindness and high fall risk were known, and that the fall could have been avoided if supervision or assistance had been provided during showering. Review of the care plan and assessments showed that while the resident's fall risk and vision impairment were documented, there were no specific interventions or measurable actions addressing her preferences or the need for supervision in the shower room, directly contributing to the incident.