Failure to Individualize Fall Prevention Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to revise and implement an individualized fall prevention plan for a resident with a known history of falls and severe cognitive impairment. The resident, who had diagnoses including vascular dementia, metabolic encephalopathy, muscle weakness, and gait instability, was assessed as high risk for falls with a fall risk evaluation score of 20. Despite having a care plan that noted a history of self-transferring and poor safety awareness, the interventions listed were general, such as anticipating and meeting needs, and reminding the resident to call for assistance, without specific strategies tailored to the resident's severe cognitive impairment. The resident experienced two falls during their stay, with the most recent resulting in a one-inch skin tear on the back of the head after being found on the floor in their room. The care plan was not updated with individualized interventions following these incidents, and the facility did not implement specific fall prevention measures that addressed the resident's significant cognitive deficits. The deficiency was identified during an unannounced visit and through interviews and record reviews with facility staff.