Failure to Develop Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the fall risk for a resident who was assessed as high risk for falls upon admission. Despite the resident's complex medical history, including diabetes, dysphagia, lack of coordination, and an above-knee amputation, there was no documented care plan targeting fall prevention. The Minimum Data Set assessment indicated the resident had moderately impaired cognition and required varying levels of assistance with activities of daily living, further underscoring the need for individualized fall prevention strategies. During a review of the resident's records and an interview with the DON, it was confirmed that the fall risk assessment identified the resident as high risk, but no corresponding care plan was found in the medical record. Facility policy requires that admission assessments be used to create an initial baseline care plan, and that fall risk assessments inform individualized plans of care. The absence of a fall risk care plan for this resident constituted a failure to meet these requirements.