Failure to Implement Care Plan Intervention for Fall Risk
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention for one resident who was identified as being at risk for falls. According to the care plan, the resident was to be taken to the dining room for meals as a fall prevention measure. However, multiple observations showed the resident eating meals in her wheelchair in the hallway outside her room, rather than in the dining room as specified. Staff interviews confirmed that the resident typically ate all meals either in her room or in the hallway, and one CNA was unaware of the care plan intervention requiring dining room meals. The Director of Nursing Services and the Administrator both acknowledged the importance of care plan development and implementation, and confirmed that the intervention for dining room meals was intended to address fall risk. The resident involved had a diagnosis of Alzheimer's Disease and was assessed as having severely impaired cognitive skills for daily decision making. Despite the established care plan and facility policy, the intervention was not carried out as intended for this resident.