Failure to Develop and Implement Care Plan for Resident's Fear of Falling and Refusal to Walk
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan addressing a resident's fear of falling and subsequent refusal to walk following multiple unwitnessed falls. The resident, who had a documented self-care performance deficit and was at risk for falls, experienced several unwitnessed falls in the bathroom and near her bed. Despite a physical therapy consult indicating the resident was unsafe to ambulate independently and required staff assistance at all times, documentation showed a decline in the resident's walking activity over several months. Staff provided some encouragement and supervision, but the resident continued to refuse to walk due to fear of falling. Interviews with facility staff, including a CNA and the DON, confirmed that the resident's fear of falling and refusal to walk were not addressed in the care plan. The Director of Staff Development also stated that such refusals and fears should be communicated and incorporated into the care plan to guide staff interventions. Review of the facility's care planning policy indicated that care plans should include measurable objectives, timeframes, and address resident refusals and psychosocial needs, but these elements were missing in this case.