Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement relevant, consistent, and individualized interventions to prevent falls for a resident identified as being at risk. The resident was admitted with multiple diagnoses, including type 2 diabetes with diabetic neuropathy, dementia, a history of repeated falls, muscle weakness, hearing loss, knee pain, and constipation. Upon admission, a fall assessment indicated a high risk for falls, with a score of 10, and identified several risk factors such as prior falls, incontinence, visual impairment, impaired mobility, environmental hazards, polypharmacy, pain, and cognitive impairment. Despite these findings, the resident's baseline care plan did not address fall risk or include interventions to prevent falls as identified in the assessment. Further documentation showed that the comprehensive care plan created prior to a care plan meeting did not address fall risks, prevention, or interventions, even though the resident had a recent fall prior to admission and this was noted in the MDS and CAA triggers. The lack of a fall prevention care plan persisted until after the resident experienced an unwitnessed fall in the facility. The care plan to prevent falls was not implemented until the day after this incident, confirming that the facility did not provide adequate supervision or individualized interventions to prevent accidents for this resident.