Failure to Address High Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan that addressed all of a resident's needs, specifically omitting interventions for fall risk. Upon admission, the resident was assessed as high risk for falls, with a documented history of one to two falls in the previous three months, disorientation at all times, chairbound status, presence of predisposing diseases, a recent change in condition, and use of medications that could increase fall risk. Despite these findings and a subsequent fall incident, the resident's care plan did not include fall risk or preventive interventions until after the fall occurred. The Director of Nursing confirmed that the care plan did not address the resident's fall risk prior to the incident.