Failure to Implement Care Plan Intervention for Fall Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as a potential fall risk. The resident, who had diagnoses including dementia, muscle weakness, anxiety, and major depressive disorder, was noted in the care plan to have a behavior of sleeping in the dining room at bedtime. The care plan directed staff to encourage the resident to sleep in their own bedroom. However, on the night of the incident, both a nurse aide and an LPN observed the resident sleeping in the dining room with the lights off but did not wake the resident or encourage them to return to their room as required by the care plan. Subsequently, the resident attempted to walk and fell, resulting in multiple minimally displaced pelvic fractures. Documentation confirmed that the resident was found on the floor in front of a chair, reported significant pain, and was transferred to the hospital for evaluation and treatment. Interviews with staff and facility leadership confirmed that the care plan intervention was not followed, and the facility's policy required that person-centered care plans be implemented by qualified staff.