Failure to Initiate Fall Risk Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to initiate a fall risk care plan for a resident who was identified as being at risk for falls. Upon admission, the resident had diagnoses including hyponatremia and nontraumatic intracerebral hemorrhage, and was documented as having severe cognitive impairment, requiring maximal to total assistance with activities of daily living. Nursing documentation prior to the incident identified multiple fall risk factors, such as disorientation, poor safety judgment, unsteady gait, and use of psychotropic medications. Despite these findings, no fall interventions were ordered and no fall risk care plan was initiated prior to the resident experiencing a fall. The resident subsequently fell and sustained a skin tear to the right elbow. Interviews with facility staff confirmed that a baseline care plan addressing fall risk should have been developed within 48 hours of admission, in accordance with facility policy. However, the care plan for fall risk was not initiated until after the fall occurred. Facility policies reviewed indicated that residents identified as at risk for falls should receive appropriate interventions and an individualized plan of care, which was not implemented in this case.