Failure to Implement Individualized Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive and individualized care plan to address fall prevention for a resident with severe cognitive impairment and high fall risk. The resident, diagnosed with dementia and muscle weakness, was unable to use the call light or effectively communicate needs, yet the care plan interventions focused on ensuring the call light was within reach and anticipating needs. Staff interviews revealed that the resident was often left unattended in his room, and the care plan did not include specific interventions such as not leaving the resident in a wheelchair unattended, despite his inability to call for help. On the date of the incident, the resident was left alone in his room in a wheelchair, resulting in a fall that caused a head injury and required hospital assessment. Staff were aware of the resident's fall risk status, but the resources available to them, such as the binder at the nurses station, did not provide individualized interventions. The care plan lacked specificity and did not address the resident's unique needs, contributing to the failure to prevent the fall.