Failure to Develop and Implement Comprehensive Fall Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, resident-centered fall care plan for a resident with a history of falls, encephalopathy, sciatica, and dementia. The resident was assessed as having mildly impaired cognitive skills and required moderate assistance with several activities of daily living, including transfers and toileting. Despite being identified as a fall risk due to balance problems, history of multiple falls, and other medical conditions, the care plan only included an intervention to place the resident in a room near the nursing station for better visibility. The resident experienced an unwitnessed fall after not using the call light to request assistance with a restroom transfer. Interviews with staff revealed that the resident often attempted to go to the bathroom independently and did not consistently use the call light, despite reminders and reeducation. Staff also noted the resident's desire for independence, forgetfulness, unsteady gait, and occasional non-compliance with safety interventions. The care plan did not address the resident's non-compliance with call light use or include additional interventions tailored to the resident's specific risks and behaviors. Further review and interviews confirmed that the facility's interdisciplinary team was aware of the resident's fall risk and history but did not update the care plan to reflect the resident's ongoing needs and behaviors. The facility's policies required comprehensive, person-centered care plans based on thorough assessments and ongoing revisions as resident conditions changed. However, the care plan for this resident lacked specific, measurable interventions to address the identified risks, leading to a deficiency in care planning.