Failure to Develop Comprehensive Fall Prevention Care Plan
Penalty
Fine: $16,981
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop and implement a comprehensive care plan addressing fall prevention for a resident who was identified as being at risk for falls. The resident experienced a fall resulting in bruising to the forehead, ankle, and knee, and was subsequently diagnosed with a cerebral infarction. Although a fall risk evaluation and care plan review were conducted, the interventions listed in the care plan were limited to encouraging fluid intake and monitoring for symptoms such as nausea, vomiting, and changes in medical, pain, or mental status, without specific fall prevention strategies. This deficiency was confirmed through record review and staff interviews.