Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and document new fall prevention interventions for two residents with a history of falls. Resident #1, who has diagnoses including cerebral infarction and traumatic brain injury, experienced falls on two separate occasions when being transferred to bed. Despite these incidents, no new fall prevention strategies were added to the resident's care plan. The Director of Nursing (DON) acknowledged that the falls were attributed to behavioral issues, yet no new behavioral interventions were documented in the care plan following the falls. Similarly, Resident #6, diagnosed with heart failure and dementia, fell out of bed, but the care plan did not reflect any new interventions to prevent future falls. The Regional MDS Nurse confirmed the absence of new fall prevention measures in the care plan, and the DON admitted that there should have been new interventions documented. This lack of action increased the potential for additional falls and potential injury for these residents.