Failure to Develop Timely Baseline Care Plan for Fall Risk
Penalty
Summary
A deficiency occurred when the facility failed to develop a baseline admission care plan addressing a new resident's risk for falls within the first 48 hours of admission. The resident, who had a history of falls and multiple diagnoses including metabolic encephalopathy, osteoarthritis, osteomyelitis, low back pain, muscle weakness, and difficulty walking, was assessed as a moderate fall risk upon admission. The clinical record and facility documentation did not show that a baseline care plan was created to address this risk, despite the resident's need for extensive assistance with bed mobility and toileting, supervision for transfers, and use of assistive devices. The lack of a timely care plan persisted until after the resident experienced an unwitnessed fall, which resulted in complaints of pain and required evaluation in the emergency department. Interviews and record reviews confirmed that the expectation was for a baseline care plan to be in place for residents identified as at risk for falls, but this was not completed until after the incident occurred.