Inaccurate Fall-Prevention Care Plans for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with accurate, measurable fall-prevention interventions for two residents identified as high fall risks. For the first resident, an older female with COPD, hypoxemia, dementia, adult failure to thrive, fatigue, and a history of falls, the quarterly MDS showed severely impaired cognition and extensive ADL assistance needs. Her fall risk assessment (FRA) score of 28 indicated high fall risk, with multiple recent falls, inability to stand independently, and loss of balance. Despite this, her comprehensive care plan listed hipsters as an intervention, even though she did not wear them, and did not include the actual fall-prevention measures in use: a low bed, non-skid socks, and anti-skid tape on the floor next to her bed. Surveyor observations confirmed that this resident was using a low bed, non-skid socks, and anti-skid tape, and was not wearing hipsters during multiple observations. Interviews with nursing and CNA staff who regularly cared for her consistently stated that she did not use hipsters, that hipsters had been tried but she refused them and removed them, and that her current fall-prevention measures were the low bed, non-skid socks, and anti-skid tape. Staff also explained that CNAs rely on the Kardex, which is generated from the care plan, to know and implement resident-specific interventions, underscoring the importance of care plan accuracy. The second resident, an older male with type 2 diabetes mellitus, difficulty walking, vascular dementia, insomnia, and a history of falls, also had severely impaired cognition and required extensive ADL assistance. His FRA score of 23 indicated high fall risk, with loss of balance while standing and need for direct assistance for mobility. His comprehensive care plan for falls did not include the fall-prevention interventions actually in place: anti-skid strips/tape on the floor, non-skid socks, anti-tip devices on his wheelchair, and a low bed. Surveyor observations and staff interviews confirmed that he had a low bed, non-skid socks, anti-skid tape on the floor, and anti-tip devices on his wheelchair, but these interventions were not reflected in his written care plan, contrary to facility policy requiring comprehensive person-centered care plans with measurable objectives and timeframes.
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