Failure to Develop and Implement Fall Risk Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans addressing fall risk for two residents who had documented histories of falls and related diagnoses. For the first resident, who was cognitively intact and had a left knee fracture, the Minimum Data Set (MDS) admission assessment triggered the need for a fall risk care plan, but none was created. This resident experienced multiple falls during their stay, as documented in nursing progress notes and event reports, yet the care plan was not updated to address fall risk. The MDS Nurse confirmed that the care area assessment for falls was triggered and acknowledged that a fall risk care plan should have been initiated but was missed. The MDS Nurse also did not attend weekly interdisciplinary team (IDT) meetings where care plans were to be reviewed and updated, and the Interim Director of Nursing (DON) confirmed that the care plan should have been updated during these meetings. Similarly, the second resident, who had severe cognitive impairment and a history of falls, also did not have a fall risk care plan in place despite the MDS assessment triggering the need for one. This resident experienced several falls during their stay, as documented in nursing progress notes. The MDS Nurse again confirmed that the fall risk care plan was not developed as required and stated it was missed. The Interim DON reiterated that the care plan should have been updated during weekly IDT meetings, but the MDS Nurse's absence from these meetings contributed to the deficiency. The Administrator confirmed that the MDS Nurse was responsible for developing the fall risk care plans for both residents.