Failure to Implement Post-Fall Care Plan and IDT Review
Penalty
Summary
The facility failed to implement its policy and procedure for comprehensive, person-centered care planning following a resident's fall. After a non-verbal, bedbound resident with multiple diagnoses, including right knee osteoarthritis, hypertension, and ataxia, slid out of a wheelchair and onto the floor, the facility did not conduct an Interdisciplinary Team (IDT) meeting or document a post-fall care plan. The resident was identified as high risk for falls, and the facility's policy required measurable objectives and timetables to be developed and implemented after such incidents. However, there was no evidence of an IDT meeting or updated care plan in the resident's records after the initial fall. Subsequently, the same resident experienced another fall, sliding out of bed and onto the floor. Staff returned the resident to bed without notifying the charge nurse or supervisor and without a qualified staff member assessing for injuries. This resulted in the resident sustaining a fractured femur, enduring hours of pain, and requiring transfer to a general acute care hospital. Interviews with facility staff confirmed that required documentation and care planning were not completed after the initial fall, and the lack of these actions may have jeopardized the resident's safety.