Failure to Implement Fall Prevention and Investigate Incidents
Penalty
Summary
The facility failed to thoroughly investigate incidents and implement interventions to prevent future falls or accidents for two residents. For Resident 83, there was a physician's order for bilateral fall mats beside the bed, but the plan of care did not include this intervention. Observations revealed that only one fall mat was placed on the left side of the bed, contrary to the physician's order. Additionally, staff assisted Resident 83 to sit on the side of the bed for meals, which was against the plan of care that required him to be in a wheelchair or sit up in bed with a tray table. These discrepancies were confirmed during staff interviews. For Resident 164, nursing documentation noted large bruises on her abdominal area, and the resident was unaware of how they occurred. The facility's investigation suggested that the bruises might have been caused by bumping into the side of her chair or bathroom rail, but there was no documented evidence of further staff interviews or implemented interventions to prevent future occurrences. The facility's failure to conduct a thorough investigation and implement preventive measures was confirmed in interviews with the Administrator and Director of Nursing.
Plan Of Correction
The care plan for resident 83 was corrected to include the use of bilateral fall mats and to allow resident to eat while in bed. The facility is unable to retroactively provide appropriate interventions for resident 164. The facility will audit the use of fall mats to ensure that those interventions are accurately care planned and deployed as needed. The facility will review the previous 2 weeks of falls to ensure that an appropriate intervention has been implemented. Education will be provided for the CNAs to ensure that fall mats are provided for each resident as indicated in the Kardex. Education will also be provided to licensed nurses to ensure all falls have an investigation initiated that includes an immediate intervention. The IDT will be educated to ensure that all initiated facility investigations are completed and reviewed to ensure an appropriate plan is in place to prevent recurrence. The DON or designee will complete audits x5 a week for 8 weeks of 3 residents to ensure that fall mats are in place in accordance with each resident's care plan. Additional audits of resident fall investigations will occur consisting of 5 a week x 8 weeks to ensure that the facility investigation was completed and an appropriate plan was put in place to prevent recurrence. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.