Failure to Assess Fall Risk and Implement Timely Interventions Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to correctly assess a resident's fall risk, develop a comprehensive care plan, and implement timely fall prevention interventions. The resident was admitted with multiple diagnoses, including polyosteoarthritis, osteoporosis, depression, hypotension, and a recent history of falls. Despite these risk factors, the fall risk assessment inaccurately documented the resident as low risk, stating independence with ambulation and continence, which contradicted the Minimum Data Set (MDS) and comprehensive assessment findings. The care plan did not include fall prevention interventions until after the resident experienced a fall. The resident attempted to self-transfer to the bathroom during the night, resulting in an unwitnessed fall and a left wrist fracture that required surgical repair. Prior to the fall, the care plan lacked specific goals and interventions for several identified needs, including fall prevention, range of motion, self-care deficits, and management of other medical conditions. The resident was receiving medications such as diuretics and opioids, which are known risk factors for falls, and required assistance with transfers and activities of daily living, but these needs were not adequately addressed in the care plan. Interviews with staff revealed a lack of awareness regarding the resident's fall risk and the interventions in place prior to the incident. The care plan and MDS coordinator confirmed that the comprehensive care plan was not completed until several weeks after admission, and the Director of Nursing was unaware of this delay. The failure to accurately assess risk, develop a timely and comprehensive care plan, and implement appropriate interventions directly contributed to the resident's fall and injury.