Failure to Develop and Implement Person-Centered Fall Prevention Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for fall prevention for a resident who was at high risk for falls following a right below-the-knee amputation. The resident had multiple diagnoses, including peripheral vascular disease, Type II diabetes mellitus, and required assistance with personal care and transfers. Despite being identified as a high fall risk on the Morse Fall Scale, the care plan for falls included only general interventions such as anticipating needs, ensuring the call light was within reach, and following the facility's fall protocol, without specific, measurable actions tailored to the resident's unique risks. The resident experienced an unwitnessed fall while attempting to self-transfer, which resulted in the reopening of the surgical incision at the amputation site. The incident required urgent hospital treatment and surgical revision due to the severity of the wound dehiscence and associated complications, including a hematoma and exposed bone. Documentation indicated that the resident's call light was not answered and there were issues with the bed, contributing to the resident's attempt to self-transfer. Interviews and record reviews confirmed that the facility did not have an adequate fall prevention plan in place for this resident, despite clear risk factors and previous incidents. The facility's own policies required comprehensive, individualized care plans and timely risk assessments, but these were not effectively implemented for this resident, as acknowledged by the medical director and supported by the facility's documentation.