Failure to Accurately Assess Fall Risk and Develop Person-Centered Care Plan
Penalty
Summary
The facility failed to accurately assess a resident's fall risk status and develop a person-centered care plan upon admission, despite the resident's recent history of falls and significant orthopedic injuries. The resident was admitted following a fall at home that resulted in a right distal femur fracture and a fracture around an internal prosthetic knee joint. Upon admission, the fall risk evaluation incorrectly assessed the resident as moderate risk, omitting the recent fall history that led to hospitalization. The care plan interventions were based on this inaccurate assessment and did not reflect the resident's actual high risk for falls. Subsequent documentation and interviews revealed that the resident had moderate cognitive impairment, limited mobility, and required moderate assistance for transfers, as confirmed by physical therapy records. Despite these needs, the care plan only indicated general fall prevention measures and did not specify the level of assistance required. The resident later experienced a fall while attempting to transfer from the commode, resulting in a nondisplaced distal radial fracture. Staff interviews and record reviews confirmed that the facility's fall prevention protocol, which requires individualized assessment and care planning, was not properly followed for this resident.