Failure to Implement and Document Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan to address the fall risk for one resident with severe cognitive impairment and multiple medical conditions, including senile degeneration of the brain, atrial fibrillation, and hypertension. The resident required partial to moderate assistance with bed mobility and transfers and was identified as being at risk for falls due to factors such as altered balance, mental status, medication use, cardiovascular disease, decreased coordination, history of falls, unsteady gait, and visual impairment. Following an unwitnessed fall, the care plan was updated to include hourly rounding as an intervention to prevent further incidents. Despite this intervention being added to the care plan, there was no documentation in the resident's medical record to indicate that hourly rounding was being conducted as directed. Interviews with facility leadership confirmed the absence of evidence that staff were following the care plan's specified intervention. This lack of implementation and documentation of the care plan intervention constituted a failure to meet the resident's needs as outlined in facility policy and regulatory requirements.