Failure to Develop and Implement Individualized Fall Prevention Care Plan
Penalty
Summary
A resident with a history of diabetes mellitus, hyperlipidemia, severe cognitive impairment, and a documented history of falls was admitted and subsequently readmitted to the facility following an unwitnessed fall that resulted in a laceration above the right eyebrow. The resident required substantial to maximal assistance with activities of daily living and was identified as being at high risk for falls. Physician orders specified the use of low bed positioning and floor mats on both sides of the bed as fall prevention interventions. Despite these orders and the resident's high fall risk, the care plan developed for the resident did not include all individualized interventions, specifically omitting the use of floor mats as ordered by the physician. Observations confirmed that floor mats were not present at the bedside, and staff interviews revealed that this intervention was not implemented. The care plan included general fall prevention measures such as frequent visual monitoring and ensuring the call light was within reach, but failed to address all specific needs and physician-ordered interventions for the resident. The Director of Nursing acknowledged that the care plan was not individualized to include all necessary interventions, and that the physician's order for floor mats was neither carried out nor reflected in the care plan. Facility policy required comprehensive, individualized care plans with measurable objectives and timetables, but this was not achieved for the resident, resulting in a failure to fully address the resident's fall risk.