Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective interventions to prevent future falls for a resident identified as being at risk for falls due to decreased safety awareness. The resident was admitted on November 9, 2017, and a care plan was initiated on November 27, 2020, noting the risk for falls. Despite this, the resident experienced multiple falls, including an unwitnessed fall on October 10, 2024, where the resident was found on the floor with an abrasion above the ear. The facility's investigation into this incident did not result in any new interventions, and it was noted that the issue would be discussed at an interdisciplinary team meeting. Subsequent falls occurred on October 17, 2024, and December 20, 2024, with the resident being found on the floor on both occasions. Immediate actions taken included placing a pillow behind the resident's upper body and using blanket rolls on the sides of the mattress. However, these interventions were not documented in the resident's care plan. The only documentation of an interdisciplinary team meeting regarding the falls was dated January 8, 2025, after the resident had already experienced three falls. An interview with the Director of Nursing confirmed the lack of documentation and updates to the care plan to prevent further falls.
Plan Of Correction
1. Resident 5's care plan was updated to include the fall prevention interventions, which include: - Pillow placement behind upper body. - Blanket rolls on both sides of mattress. A full review of Resident 5's fall history was completed by IDT to ensure all interventions are appropriate and accurate to meet the residents needs per plan of care as well to ensure they are in place. 2. DON/IDT will complete a look back of the past 30 days of residents who had a fall. Falls will be reviewed to ensure interventions are documented in their care plan and are in place to meet the needs of the residents plan of care. Weekly IDT fall meetings will be started to review the falls during that week to ensure appropriate interventions are put in place and documented in their care plan. 3. DON/designee will provide re-education for Nursing and IDT Staff on timely documentation of fall prevention interventions in residents' care plans as well as implementation of weekly fall meetings on reviewing residents who fell and ensuring interventions are appropriate and effective to meet the needs of the resident. 4. The DON or designee will audit 5 random resident fall cases per month for three months to ensure: - Fall prevention interventions are documented in care plans post fall. - IDT meetings are held within a minimum of 72 hours of each fall. - Weekly IDT Fall meetings are held to discuss residents who fall and to ensure interventions are in place and documented in care plan and meet the plan of care needs. Audit results will be reviewed monthly by the QAPI team to assess trends and determine if ongoing monitoring is necessary.