Failure to Review, Revise, and Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to review, revise, and implement care plans for a resident with a history of falls. The resident, who has diagnoses including Alzheimer's dementia, major depressive disorder, and anxiety disorder, was dependent on staff for activities of daily living and required assistance with food and fluid intake. Despite multiple documented falls over several months, there was no evidence that the facility completed screenings, reviews, evaluations, or occupational therapy (OT) referrals as interventions following these incidents. The facility's own policies require staff and physicians to reevaluate and reconsider interventions for residents who continue to fall, and to monitor and document responses to interventions, but these steps were not documented as completed for this resident. Additionally, the resident's care plan included interventions such as non-skid strips by the bed and a fall mat on the right side of the bed, but observations on multiple dates revealed that these items were not present in the resident's room. The DON confirmed that a fall mat should have been in place when the resident was in bed. Although a printed copy of an OT referral was provided, there was no further documentation regarding the results of assessments or referrals. These failures demonstrate that the facility did not follow its own policies or ensure that care plan interventions were implemented and maintained for the resident at risk for falls.