Failure to Develop and Implement Comprehensive Fall Care Plan After Resident Fall
Penalty
Summary
A resident with a history of acute respiratory failure, muscle weakness, type 2 diabetes, and dependence on renal dialysis experienced a fall while attempting to transfer from bed to wheelchair after returning from dialysis. The resident, who had intact cognitive function and required moderate assistance for activities of daily living and transfers, reported that staff did not respond to her call for help because they were occupied elsewhere. The wheelchair had not been locked by staff, causing it to slide and resulting in the resident falling face down. The resident sustained a slight swelling on the right forehead, which later resolved. Upon review, there was no documentation of a fall risk assessment or a comprehensive, resident-centered care plan addressing falls in the resident's electronic health record following the incident. Staff interviews confirmed that neither a fall assessment nor appropriate care plan interventions were initiated after the fall. The facility's policy required individualized safety interventions and risk assessments, but these were not implemented or documented for the resident after the fall event.