Failure to Update High-Risk Fall Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan after each fall incident, as required. The resident was readmitted with multiple diagnoses including rhabdomyolysis, adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit. On admission, the resident’s mode of mobility was wheelchair, and she was documented as alert and oriented with some forgetfulness. A physician history and physical noted a recent 2‑day history of weakness and falls at home with associated dizziness and inability to ambulate. An admission Morse Fall Scale completed the same day showed a score of 65, indicating high fall risk. A comprehensive care plan dated shortly after admission identified an ADL self‑care performance deficit related to deconditioning and documented that the resident was at risk for falls related to deconditioning and gait/balance problems. Interventions initiated included encouraging participation in care, use of the call bell for assistance, anticipating and meeting needs, ensuring the call light and commonly used items were within reach, and providing prompt responses to requests for assistance. A daily skilled charting note documented that the resident had unsteady gait, poor balance, was bedfast most of the time, and sometimes refused to follow instructions, insisting on going to the bathroom even while wearing briefs. The admission MDS later showed a BIMS score of 6, indicating severely impaired cognition. The resident experienced three separate fall incidents. After the first fall, a nurse’s note documented that the resident was found sitting on the floor after slipping while trying to stand to go to the bathroom; assessments were completed, neuro checks were initiated, and fall‑related reminders and signage were implemented. After the second fall, a nurse’s note documented the resident lying on the floor, denial of head impact, initiation of neuro checks, and advice to use a walker with the walker placed within reach. After the third, unwitnessed fall, the resident was found on the floor in a prone position with a forehead laceration and a left knee skin tear, appeared confused, and was transferred to the hospital after assessment and initiation of neuro checks. Despite these three fall events and the resident’s documented high fall risk and cognitive impairment, review of the comprehensive care plan showed it was not updated after the falls on the identified dates. The DON confirmed that the resident’s fall care plan did not reflect high fall risk as indicated by the fall assessment and that the care plan was not updated after the fall incidents, contrary to facility policy requiring interdisciplinary review and implementation of individualized fall prevention interventions.
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