Failure to Include Fall Prevention in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan (BCP) was developed within 48 hours of admission to address a resident's high risk for falls. Upon admission, the resident had a documented history of repeated falls, left-sided weakness, was non-ambulatory, and required assistance with transfers and dressing. The admission and fall risk assessments both indicated the resident was at high risk for falls, yet the BCP did not include any mention of the resident's fall history or interventions to prevent falls. Subsequently, the resident experienced a fall while attempting to reach for clothes independently, resulting in injury to the shoulder and head, and required transfer to an acute hospital. Interviews with facility staff, including an LVN, DON, and ADON, confirmed that the BCP lacked necessary fall prevention interventions and did not communicate the resident's fall risk to staff. The facility's policy required a baseline care plan to address immediate health and safety needs, but this was not followed in the resident's case.