Failure to Initiate and Update Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident who was assessed as high risk for falls and dependent in activities of daily living (ADLs). Upon admission, the resident was identified as having a high fall risk, but no individualized care plan addressing this risk was initiated. Documentation showed that the resident was totally dependent on staff for mobility, toileting, and other ADLs, with severe cognitive impairment and medical conditions affecting coordination and gait. Despite these risk factors, the admission care plan did not include fall prevention interventions, and no baseline care plan for fall risk was documented within the required timeframe. Following an unwitnessed fall, the facility did not update the care plan or implement new interventions as required by policy. The resident experienced multiple unwitnessed falls, including incidents where the resident slid out of bed or was found on the floor, sometimes attempting to use a urinal independently. After each fall, staff failed to analyze the causes, revise the care plan, or implement additional safety measures. Interviews with nursing staff and the DON confirmed that care plans were not updated after falls, and interventions such as frequent checks, floor mats, or medication reviews were not consistently implemented. As a result of these failures, the resident suffered multiple falls, one of which resulted in a laceration to the forehead, thoracic spine strain, and left shoulder contusion, requiring transfer to an acute care hospital. The facility's own policies required prompt assessment, care plan updates, and implementation of interventions after falls, but these procedures were not followed. The lack of timely and individualized care planning, failure to update interventions after repeated falls, and inadequate adherence to fall prevention protocols directly contributed to the resident's injuries.