Failure to Timely Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to implement a timely and appropriate plan of care to prevent potential injuries for a resident with significant fall risk factors. Upon admission, the resident had a history of multiple recent falls, advanced dementia, and a lumbar fracture, and was unable to communicate effectively. Although the facility's fall prevention policy required completion of a fall risk assessment and baseline care plan (BCP) upon admission, no Falls Tool UDA assessment was completed, and the BCP was not available in the care plan binder at the time of review. The resident was placed on alarms at the request of a family member, and staff were instructed to move the resident closer to the nurses' station, but these interventions were not documented in a timely care plan. The resident was monitored for various health conditions, but the lack of a completed BCP and fall risk assessment meant that individualized interventions to prevent accidents were not formally established or communicated to staff. Subsequently, the resident was found on the floor after an unwitnessed fall, resulting in an abrasion to the right eyebrow. Interviews with staff confirmed that the BCP was not completed within the expected timeframe, and the Director of Nursing acknowledged that interventions were not implemented in a timely manner to prevent accidents for this resident.