Failure to Timely Develop Baseline Fall Prevention Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to timely develop baseline care plans with fall prevention interventions for two residents who were identified as high risk for falls upon admission. Both residents had diagnoses including muscle weakness, abnormalities of gait and mobility, and, in one case, Alzheimer's disease. Fall risk assessments conducted at admission indicated high risk scores for both individuals. Despite these findings, no baseline care plan addressing fall prevention was created within the required timeframe for either resident. For one resident, the fall prevention care plan was not developed until 26 days after admission, and for the other, it was created seven days after admission. The Director of Nursing confirmed that both residents were assessed as high risk for falls at admission but acknowledged that baseline care plans with fall prevention interventions were not developed as required. Facility policy mandates that a person-centered baseline care plan be developed within 48 hours of admission, and that nursing staff create a care plan with interventions to reduce fall risk, which was not followed in these cases.