Failure to Develop and Document Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan addressing fall risk for one resident who had a documented history of repeated falls, muscle weakness, and difficulty walking. Despite the resident being identified as high risk for falls through a Fall Risk Evaluation and experiencing two unwitnessed falls during their stay, the care plan did not include any mention of fall risk, the falls that occurred, or the interventions that were put in place. The facility's policy required holistic care plans with specific goals, objectives, and interventions, but this was not followed for the resident in question. Prior to and after the falls, several interventions were implemented, such as a yellow dot sticker to alert staff, non-slip strips, bilateral bedrails, encouragement to use a wheelchair, and provision of a reacher. However, these interventions were not documented in the resident's care plan. Interviews with facility staff confirmed that while interventions were in place, they were not reflected in the care plan, and the resident's risk for falls was not documented as required.