Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and document care plan interventions for a resident identified as high risk for falls. The resident had a history of multiple fractures and repeated falls, and the care plan specifically required visual checks to be performed and documented every shift. However, there was no documentation that these visual checks were completed as required. This omission was confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged that the care plan interventions were not followed or recorded as part of the nursing measures. As a result of the failure to implement and document the required visual checks, the resident experienced an unwitnessed fall that led to multiple pelvic fractures and required hospitalization. The facility's own policies and procedures mandated comprehensive care planning with measurable objectives and documentation of all services provided, but these were not adhered to in this case. The lack of adherence to the care plan and documentation requirements directly contributed to the resident's fall and subsequent injuries.