Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop a resident-centered care plan following a fall experienced by one of the residents. The resident, who was admitted with diagnoses including muscle weakness, diabetes mellitus, and hemiplegia, was found sitting on the floor in his room. Documentation indicated that the resident required significant assistance with activities of daily living, including being dependent or requiring maximal assistance for mobility and transfers. Despite these needs and the occurrence of a fall, there was no care plan initiated to address the incident or to implement interventions for the resident's safety. Interviews and record reviews confirmed that the MDS Nurse acknowledged the absence of a care plan after the fall and recognized that the facility's policy required the development of care plan interventions to prevent further falls. The facility's policies also specified that the interdisciplinary team should create a comprehensive, person-centered care plan with measurable objectives and time frames based on the resident's assessment. However, these procedures were not followed after the resident's fall, resulting in a lack of documented interventions to address the identified risk.