Failure to Implement Safety Interventions and Notify Physician
Penalty
Summary
The facility failed to implement safety interventions to prevent falls and did not notify the physician as required by their policy for a resident with cognitive impairment and mobility issues. The resident, who was at risk for falls due to hemiplegia, hemiparesis, and altered mental status, experienced multiple unwitnessed falls over a period of time. Despite these incidents, the facility did not put additional interventions in place to address the resident's fall risk. Furthermore, the facility's documentation lacked evidence of completed interventions such as a bowel and bladder assessment and safety checks every 15 minutes, which were supposed to be implemented after specific falls. Additionally, the physician was not notified of a fall on one occasion, contrary to the facility's policy. The Director of Nursing confirmed these lapses in safety interventions and communication with the physician.
Plan Of Correction
Resident 146 has safety interventions in place to prevent falls. Physician has been notified of any fall. An initial audit will be completed by the Director of Nursing/Designee on current residents who have fallen to ensure safety interventions were put in place and physicians have been notified of the fall. Licensed Nursing staff will be re-educated on following up to ensure fall interventions are in place, including documentation as needed and notification of the physician. Resident falls will be reviewed at clinical meetings to ensure safety interventions are implemented and physicians are notified when a fall occurs. The DON/designee will conduct a weekly random audit on five resident falls for 90 days to ensure safety interventions were implemented and the physician was notified. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.