Failure to Develop and Implement Individualized, Measurable Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan with measurable objectives and timeframes to address the needs of a resident with severe dementia and a history of falls. The resident, who was admitted with a primary diagnosis of unspecified dementia and demonstrated severe mental impairment, required assistance with activities of daily living and had a history of multiple falls within a three-month period. The care plan identified the resident as a fall risk and listed general interventions such as keeping the bed in a low position, ensuring the call light was within reach, and maintaining a clutter-free environment. However, the care plan did not include individualized or measurable objectives specifically tailored to prevent falls for this resident. Record review and staff interviews revealed that the resident was mobile using a wheelchair and walker, and was independent with transfers but lacked personal safety awareness due to cognitive impairment. Incident reports documented a witnessed fall from the wheelchair while the resident was attempting to pick up a blanket, resulting in hematomas and a subsequent emergency room evaluation. Staff interviews indicated that the resident was not redirectable, and while staff attempted to supervise and redirect her, they acknowledged the lack of specific interventions in the care plan to address her fall risk. Staff also reported that 1:1 supervision was not feasible due to staffing limitations. Further interviews with facility leadership and the hospice case manager confirmed ongoing challenges in identifying effective interventions to prevent falls for the resident. The Director of Nursing and Administrator acknowledged the care plan's lack of specificity and measurable objectives, and noted unsuccessful attempts to find alternative placement for the resident. Despite ongoing communication with the resident's family and hospice provider, the facility had not developed or implemented a comprehensive, individualized care plan to address the resident's fall risk.