Failure to Develop Comprehensive Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, resident-centered care plan to prevent falls for a resident with significant risk factors. The resident had a history of falls, bilateral leg weakness, and was dependent on staff for bed mobility and incontinent care. The resident was also using a low air loss mattress (LALM), which increases the risk of falls due to its shifting surface. Despite these factors, the care plan did not specify the type or number of staff assistance required during incontinent care, nor did it include interventions tailored to the resident's needs while on the LALM. On the day of the incident, a CNA was providing incontinent care to the resident and prompted the resident to turn. The resident subsequently slid off the bed and fell to the floor, sustaining complaints of pain but no visible bruising or discoloration. The CNA was unaware of the recommendation that two staff members should be present during incontinent care for residents on a LALM. Interviews with other staff, including another CNA, the RN, the DON, and the MDS nurse, confirmed that the care plan lacked specific instructions regarding the required assistance and interventions to prevent falls during such care. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the care plan for this resident did not address the specific risks associated with the resident's condition and equipment, nor did it communicate the necessary precautions to staff. This omission directly contributed to the resident's fall during routine care.