Failure to Develop Comprehensive Fall Prevention Plan and Complete Accurate Fall Risk Assessment
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan and complete an accurate initial Fall Risk Evaluation for a resident identified as high risk for falls. The resident, who had a history of falling, hypertension, depression, impaired cognition, and required substantial assistance with activities of daily living, was admitted and readmitted to the facility. The Fall Risk Evaluation form for this resident was incomplete, with several key assessment questions left blank, resulting in an inaccurate fall risk score. The care plan noted the resident was at high risk for falls but only included a general intervention for staff to observe the resident frequently, without specifying detailed or individualized interventions to prevent repeated falls. Staff interviews revealed that the resident was confused, incontinent, had an unsteady gait, and was known to attempt to get up independently despite being unsafe to do so. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) acknowledged that the resident was a fall risk and described facility practices such as using tab alarms and rounding every two hours for fall prevention. However, the resident did not have a tab alarm in place, and there was no documented evidence that two-hourly rounds or other specific interventions were consistently performed for this resident. The facility's own policies required monitoring and documentation of interventions for fall risk residents, but these were not followed or documented in this case. As a result of these deficiencies, the resident was found on the floor in pain after a fall, which led to a right hip fracture requiring hospitalization and surgery. The incomplete assessment and lack of individualized, documented interventions contributed to the failure to prevent the fall and subsequent injury. Facility leadership, including the MDS Nurse and DON, confirmed that the assessment was incomplete and that missing information could lead to inaccurate care planning and potential harm.