Failure to Assess and Care Plan for High Fall-Risk Resident After Community Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess, educate, and implement care plan interventions for a resident identified as being at high risk for falls, despite having a fall management policy requiring such actions. The facility’s Fall Management policy stated that all residents would be assessed for fall risk, that individualized care plans would be implemented for residents at high risk, and that interventions would be re-evaluated after a fall. The policy also required review of incidents, IDT risk management, and care plan initiation or revision after falls, with all falls reviewed during QAPI meetings. Training records showed that all staff had completed in-service trainings on fall prevention on two occasions. The resident involved was an older adult with diagnoses including bipolar disorder, underweight, muscle weakness, fatigue, and reduced mobility, and was not cognitively intact, with a BIMS score of 6/15. The MDS documented that the resident required set-up assistance with ADLs and had sustained a fall. Nursing progress notes showed that the resident fell in the community and was sent to the hospital, where he was found to have a left radial fracture, abrasions on knees and palms, bodily pain, and left knee pain, with significant difficulty ambulating afterward. An IDT risk management note documented that the resident lost balance and fell while out in the community, and a nursing fall risk assessment completed shortly after the fall identified the resident as a high fall risk. Occupational therapy notes indicated the resident was on fall risk precautions. Despite these findings, the comprehensive care plan contained no fall-related focus or interventions, and no further nursing fall risk assessments were completed after the initial high-risk assessment. The EMR did not show any assessment of the resident’s ability to safely leave the facility independently or any education provided on community safety, even though the resident reported going out alone daily and using a walker due to fear of falling again. Observations showed the resident ambulating in the hallway using a front-wheeled walker with one hand while using the other hand to hold up his pants, which he secured with a rubber glove tied through belt loops. Staff interviews revealed that the LPNs on duty did not identify any current residents as fall risks, the DON stated that a fall risk care plan was not developed because the facility only care planned for factors controllable within the facility, and the physician and PT both considered the resident a fall risk based on his diagnoses, prior fall, and mobility issues, with the PT noting that a four-wheeled walker would provide more stability for the resident in the community.
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