Failure to Revise Fall Care Plan to Include Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize a resident’s care plan to include person-centered safety measures such as staff supervision and monitoring, despite multiple indicators of high fall risk. The resident was admitted with a history of falls and a left femur fracture, anxiety disorder, gait and mobility abnormalities, and muscle weakness. A Morse Fall Risk Screen identified the resident as high risk for falls, and a PT evaluation documented decreased strength, functional mobility, postural alignment, poor standing balance, and impaired safety awareness, with risk factors including falls and further functional decline. An MDS assessment showed moderate cognitive impairment and a need for substantial/maximal assistance with ADLs and partial/moderate assistance with transfers and walking. The initial care plan for high risk of falls, dated shortly after admission, included general interventions such as assistance with ADLs, transfers, ambulation, and toileting, but did not specify monitoring or supervision parameters. After an unwitnessed fall in which the resident slid off the bed while using a urinal, an IDT meeting documented that the resident perceived himself as independent and forgot to call for assistance, and added a falling star program as a new intervention. A care plan for this actual fall focused on assessing for pain or injury and educating the resident to call for help, but again did not address monitoring or supervision. Subsequent unwitnessed falls occurred with similar circumstances of the resident sliding from the bed, and IDT documentation again cited the resident’s perception of independence and forgetting to use the call light. Following each of the additional unwitnessed falls, new care plans were created that emphasized post-fall assessments such as checking range of motion, neuro checks, PT consults, vital signs, and reinforcing the need to call for assistance, as well as environmental measures like keeping areas free of clutter. However, none of these care plans specified the frequency or level of staff monitoring or supervision for this high-risk resident. Interviews with an LVN, the ADON, and the DON confirmed that the care plans did not include clear directions on monitoring or supervision, despite facility practice and policy indicating that high fall-risk residents should receive frequent monitoring and that care plans must be revised when resident condition changes or when desired outcomes are not met.
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