Failure to Develop and Implement Comprehensive Care Plan for Resident with Poor Mobility and Balance
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident's poor mobility and balance, as required by facility policy. The resident, who had diagnoses including Alzheimer's disease, cerebral infarction, and dementia, was assessed as having severe cognitive impairment and was dependent on staff for all activities of daily living, including transfers and personal hygiene. Despite documented poor trunk control, poor sitting and standing balance, and a tendency to lean forward or to the sides, the care plan only indicated general assistance with activities of daily living and did not specifically address the resident's mobility and balance deficits. Multiple assessments, including the Minimum Data Set and a mobility assessment, identified the resident as having poor ability to sit up unassisted and maintain balance, requiring total assistance while seated in a wheelchair or shower chair. Interviews with the Director of Rehabilitation and the MDS nurse confirmed that the resident's poor trunk control and tendency to lean forward or to the sides increased the risk of falls, and that interventions such as a reclining wheelchair or shower chair could have provided additional safety. However, these specific interventions were not included in the resident's care plan, and the facility did not have a reclining shower chair available for use. As a result of these omissions, the resident sustained a fall in the shower room while sitting in a shower chair, resulting in a laceration to the forehead, a nondisplaced fracture of the first cervical vertebra, a forehead hematoma, and blunt head trauma. The incident led to the resident being sent to an acute care hospital for further evaluation and treatment. Facility leadership confirmed that a care plan addressing the resident's poor mobility and balance was not developed prior to the fall, despite assessments indicating the need for such interventions.