Failure to Develop and Implement Person-Centered Fall Prevention Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address the needs of two residents with a history of multiple unwitnessed falls related to self-ambulation. Despite documented policies requiring individualized interventions, ongoing monitoring, and evaluation of fall prevention strategies, the care plans for these residents lacked evidence of appropriate and updated interventions following repeated falls. Interventions were limited to environmental reminders, such as signage and call bells, without documented reassessment or modification in response to continued incidents. One resident with severe cognitive impairment, dementia, and a history of falls experienced five unwitnessed falls over a three-month period. The care plan interventions remained unchanged after each event, focusing only on encouraging call bell use and providing partial assistance, despite staff acknowledging the resident's reluctance to use the call bell. Interviews with staff and the physician confirmed the resident was a frequent faller and required frequent checks, but there was no documentation of increased monitoring or revised interventions in the care plan. Another resident with moderate cognitive impairment, Parkinson's disease, and a history of repeated falls experienced 30 falls, 20 of which were unwitnessed, over a two-year period. The care plan lacked active interventions for transfer or ambulation, and previously implemented strategies such as walker assistance and scheduled toileting had been discontinued without evidence of ongoing monitoring or revision. Staff interviews revealed there was no formal protocol for increased checks or monitoring for frequent fallers, and the interdisciplinary team did not consistently review or update interventions in response to continued falls.