Failure to Accurately Assess Fall Risk and Implement Care Plan Interventions
Penalty
Summary
The facility failed to provide resident-centered care and services for a resident by not accurately assessing the resident's fall risk prior to two fall events. The resident, who had diagnoses including schizophrenia, anxiety disorder, and type 2 diabetes mellitus, was marked as low fall risk in the facility's assessments, despite being prescribed multiple psychotropic medications and using a wheelchair. The assessments did not reflect the resident's actual medication regimen or mobility status, resulting in a fall risk score that was lower than appropriate. The DON confirmed that the assessments were inaccurate and that all residents on psychotropic medications should be considered high fall risk. After the resident experienced a fall, the interdisciplinary team recommended an intervention for staff to encourage the resident to wait in her room for her meal tray, which was added to the care plan. However, there was no documented evidence that this intervention was implemented or monitored by staff between the first and second fall events. The resident subsequently fell again while attempting to get her breakfast tray, resulting in a left femur fracture and transfer to an acute care hospital. The facility's policy required staff to monitor and document the resident's response to fall interventions, but this was not done. Additionally, following the second fall, the facility failed to complete and document orthostatic blood pressure measurements as indicated in the post-fall SBAR and required by facility policy. There were no recorded orthostatic blood pressure readings for the resident between the time of the fall and her transfer to the hospital. The DON confirmed that the required measurements were not documented, and the SBAR response was not accurate. Facility policy required documentation of blood pressure measurements, including date, time, and the name of the person recording the data, but this was not followed.