Failure to Investigate Falls and Ensure Correct Interventions
Penalty
Summary
The facility failed to fully investigate two falls involving a resident, R804, and did not ensure that correct interventions were in place. R804 was transferred to the hospital emergency room due to low blood pressure, where it was discovered that the resident had multiple fractures in both femurs. The facility did not report these injuries to the hospital upon admission, and the incident was later addressed as an injury of unknown origin. R804's clinical record indicated a high risk of falls, with a Fall Risk Assessment score of 20. Despite this, the facility did not complete recommended follow-up radiographs after initial x-rays showed abnormal findings. The resident experienced two falls, one on 12/6/24 and another on 12/10/24, during transfers. The facility's documentation was incomplete, lacking interviews with involved CNAs and failing to identify all staff present during the incidents. Additionally, the care plan intervention to use a two-person assist for ambulation was not consistently documented or followed. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition and the necessary follow-up actions. Nurse F was unaware of the need for additional x-rays, and the Director of Nursing did not believe the falls caused the fractures, despite the lack of thorough investigation. The facility's fall prevention policy was not effectively implemented, as evidenced by the inadequate tracking and intervention for R804's falls.
Plan Of Correction
1. Resident 804 no longer resides in the facility. 2. All residents that are categorized as “High Risk for Falls” based on their most recent fall assessment, or residents that have sustained a fall in the last 30 days, have the potential to be affected by the alleged deficient practice. By 3/7/2025, these identified residents will have their fall Care Plan reviewed by the Clinical IDT team to ensure appropriate fall interventions were in place and updated as needed. Any resident that has sustained a fall in the last 30 days will have their chart reviewed to ensure an IDT RCA along with a complete physical assessment of the resident has been completed and documented. 3. By 3/7/2025, the DON/designee will provide the following to all Clinical IDT members and licensed nurses: a. Fall Investigation Education with specific attention on determining and documenting the root cause of fall. b. Fall Prevention Education with specific attention on implementation of appropriate interventions. 4. The DON/designee will review 5 residents with sustained falls to ensure that a root cause analysis has been completed and documented, with immediate implementation of post-fall intervention along with a complete physical assessment of the resident. This review will occur 5 days per week for 4 weeks, then monthly thereafter for 3 months, or until substantial compliance has been maintained. Results will be presented monthly at the QAPI meeting for committee review. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 3/7/2025 and for sustained compliance thereafter.