Failure to Individualize Fall-Prevention Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized fall-prevention interventions for a resident with severe cognitive impairment and a history of forgetting to use her walker. The resident, diagnosed with dementia and requiring supervision and assistance for transfers and ambulation, was known to be impulsive and easily distracted, with a BIMS score of 00 indicating severe cognitive deficits. Despite these documented needs and behavior patterns, the care plan did not include specific interventions to ensure the resident's walker was kept within reach or address her tendency to ambulate without it. As a result of this omission, the resident was left unattended without her walker after being assisted to her room, during which time she attempted to follow her cousin and fell. This incident led to the resident sustaining a head laceration and a right hip fracture, requiring hospitalization and surgery. Staff interviews confirmed awareness of the resident's impulsivity and forgetfulness regarding her walker, yet the care plan lacked tailored strategies to mitigate these risks.