Failure to Implement Fall Management Program in High-Risk Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included a Fall Management Program for a resident assessed as high risk for falls. The resident, who had a history of cerebral infarction resulting in left side hemiplegia and required assistance with activities of daily living, was identified as high risk for falls based on the Morse Fall Scale and interdisciplinary team assessments. Despite these findings, the care plan only included general interventions such as encouraging the resident to use the call light and attempting to anticipate needs, without incorporating the facility's established Fall Management Program. Interviews with facility leadership confirmed that the Falling Star Program, which includes specific interventions like a low bed, fall pad, colored wristband, and star magnet, should have been included in the care plan for residents at high risk for falls. Review of facility policies indicated that such interventions are required for residents with high fall risk, but documentation showed these were not implemented for the resident in question. This omission resulted in the resident's care needs not being thoroughly addressed.