Failure to Implement Fall Risk Policy and Update Care Plan for Resident with Repeated Crawling Behavior
Penalty
Summary
The facility failed to implement its Falls and Fall Risk Management Policy and Procedure for one resident who was at high risk for falls due to a history of falls, confusion, impaired gait and balance, and use of antihypertensive medication. The resident's care plan included interventions such as providing bilateral floor mats, keeping the call light within reach, and maintaining a safe environment. However, staff did not assess the resident for injury whenever he was found crawling on the floor mats, as required by the care plan. Additionally, the resident's care plan was not updated to reflect his repeated behavior of crawling on the floor, despite multiple staff observations and reports from a roommate that the resident crawled out of bed and around the room several times a day. Staff, including a CNA and the DON, confirmed that the resident frequently crawled on the floor and sometimes into the hallway, but the care plan did not address this specific behavior. Furthermore, an LVN failed to document the use of a wander guard device trial in the resident's medical record, contrary to facility policy. The DON acknowledged that documentation and care plan updates were not completed as required, and that staff did not consistently follow procedures for monitoring and assisting the resident when found on the floor. These failures placed the resident at risk for harm and injury.