Failure to Develop Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing fall risk for a resident who was identified as high risk for falls. The resident, who had diagnoses including atherosclerotic heart disease, hypertension, and dementia with fluctuating decision-making capacity, was assessed multiple times with fall risk scores significantly above the threshold for high risk. Despite these assessments, no care plan was created to address the resident's fall risk prior to a fall incident. Record reviews showed that the resident required substantial to partial assistance with activities of daily living and had moderate cognitive impairment. Interviews with nursing staff confirmed that the resident's high fall risk status was known for several months, but appropriate interventions and a care plan were not put in place. The facility's own policy required a comprehensive, person-centered care plan based on assessed needs, which was not followed in this case.