Failure to Develop Individualized, Measurable Fall Care Plans for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered, and individualized fall care plans for multiple residents with known fall risks and/or fall histories. For one resident with dementia, a high fall risk score, and a documented fall resulting in right distal radial and ulna fractures, the fall care plan contained only a generic goal that the resident would have a safe environment maintained through the next review. This goal was system-generated, not customized, and did not include measurable, resident-specific outcomes despite the resident’s recent fall and injury. Another resident with a history of falling, epilepsy, bilateral lower extremity amputations, dementia, and altered mental status also had a fall care plan with the same broad, non-individualized goal, without specific, measurable objectives tailored to that resident’s complex conditions and fall risk. A third resident with dementia, schizoaffective disorder, low back pain, and a nondisplaced intertrochanteric fracture of the right femur had progress notes documenting repeated attempts to throw himself out of a chair in the dining area and then leaping onto the floor. Staff documented monitoring the area and assisting the resident back to a chair, but no enhanced or one-to-one supervision was implemented prior to the fall. Despite these behaviors and the fall event, this resident’s fall care plan also contained only the generic goal that a safe environment would be maintained through the next review, without individualized, measurable goals addressing his specific behavioral and fall risks. A fourth resident with generalized arthritis, chronic pain, left knee pain, syncope and collapse, weakness, and an unspecified fall had a high fall risk score and a documented incident in which the resident was found lying on the floor after stating they had tried to get into a chair and fell. This resident’s fall care plan, in place for several years, likewise contained only the broad goal of maintaining a safe environment through the next review, without measurable, person-centered outcomes related to the resident’s identified fall risks and prior fall. Interviews with the MDS Coordinator and Restorative Nurse Consultant confirmed that the facility routinely used this system-generated fall goal for all residents, acknowledged that it was broad and general, and that goals should be measurable, person-centered, and tailored to each resident’s specific needs, but the care plans reviewed did not reflect such individualized, measurable fall-related goals.
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