Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. Resident #2, with a history of falls and requiring moderate assistance for transfers, experienced multiple falls from their wheelchair over a two-month period. Despite these incidents, there was no documented evidence of new interventions being implemented to prevent further falls, and the resident's care plan was not updated accordingly. Resident #3, who was cognitively intact but had poor safety awareness, also experienced several unwitnessed falls, some resulting in minor injuries. The resident's care plan included interventions such as anti-skid socks and a well-lit environment, but there was no documentation of new interventions following each fall. The Director of Nursing acknowledged the resident's poor safety awareness and confusion but did not provide evidence of additional measures taken to prevent further falls. Interviews with the Director of Nursing and the Administrator revealed that while the facility held regular meetings to discuss fall risks and safety interventions, there was a lack of documented follow-up actions or new interventions for the residents involved. The facility's failure to update care plans and implement effective fall prevention strategies contributed to the ongoing risk of accidents for these residents.
Plan Of Correction
Plan of Correction: Approved January 29, 2025 Plan for affected Resident: Resident #2 continues wheelchair pad alarm and remains in supervised area for safety. All fall interventions will be documented on updated care plan at the time of fall and reviewed at the risk meeting weekly. Resident has not had any recent falls. Resident #3 is no longer at the facility. Plan to identify other potentially affected residents: All admissions and readmission fall risk assessments will be reviewed upon admission and each quarter to ensure the appropriate interventions are in place to aid in the prevention of falls based upon the resident risk category. Resident charts were audited from (MONTH) 1st 2024 to current for residents that are at risk for falls to ensure that appropriate interventions are in place. Plan for system changes and measures to prevent recurrence: The fall policy was reviewed and updated. The facility will take the following measures to ensure the problem does not reoccur: Nurse educator/designee will re-educate all licensed nursing staff on Fall Risk assessment and Fall Prevention. All CNA’s will be in-serviced on fall prevention by Staff Educator/designee. All new admissions/readmissions and any incident or accident that took place the day before will be reviewed at the morning IDT meeting to ensure that interventions are in place and properly documented. All new admission & re-admission resident charts will be audited weekly by ADON/Designee. Additionally, those residents who are at risk of falls will be in a supervised area for safety. Daily Environmental rounds will be conducted by nurse managers/supervisor and nurse educator to ensure the unit is free from accident hazards as is possible. Nursing staff will rotate supervised areas to ensure adequate supervision is being provided for residents that are at risk, as documented on the CNA assignment. Plan for monitoring corrective action: The facility plans to monitor its performance to make sure that solutions are substantiated by doing weekly audits that will be conducted by the nurse managers/designee to ensure all residents discussed at the at-risk meeting/admission and readmission have fall interventions with date in place. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2) thereafter.