Failure to Develop Person-Centered Fall Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan related to falls for one of five residents. The resident in question was admitted following hospitalization due to falls and was identified as high risk for further falls, with multiple diagnoses including anemia, cancer, and multiple fractures. Despite the facility's policy requiring a resident-centered falls prevention plan based on assessment information, the care plan for this resident only included the intervention to keep the call light within reach, with no other documented fall prevention measures. The resident experienced a fall, resulting in a skin tear, and was found on the floor next to the bed with the call light in reach but not activated. Fall mats were only added as an intervention after the incident. Documentation showed that the resident had terminal restlessness and agitation, and experienced new or worsening pain and urinary incontinence following the fall. The care plan had not been updated with additional fall prevention interventions prior to the incident, despite the resident's high risk status and recent fall history. The lack of a robust, individualized fall care plan was confirmed by the facility, and the deficiency was identified as past non-compliance.