Failure to Initiate Fall Care Plan for High-Risk Resident
Penalty
Summary
A resident with a history of left artificial hip joint, type II diabetes, and Alzheimer's disease was admitted to the facility and identified as needing assistance with activities of daily living due to physical and mental impairments. The resident was assessed as a high risk for falls based on a fall risk assessment score of eighteen and had a documented fall in the month prior to admission. Despite these findings, the facility did not initiate a fall care plan or implement specific fall prevention interventions at the time of admission or upon identification of high fall risk. The lack of a fall care plan persisted until after the resident experienced a fall resulting in a right knee femur fracture, which required surgical repair. The care plan addressing fall risk and related interventions was only created following this incident. Facility documentation and interviews confirmed that the Director of Nursing was unaware that a fall risk care plan had not been implemented, despite facility policy requiring such a plan for residents identified as high risk for falls.