Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and implement care planned interventions for a resident with a known high risk for falls. The resident, an 82-year-old male with a recent left hip fracture, post-surgical revision, and multiple comorbidities including peripheral vascular disease, hypertension, diabetes, and anemia, was admitted to the facility. The resident's care plan included specific fall prevention interventions such as a low bed, floor mat, non-skid footwear, and placement of wedges at the right shoulder and knee when resting in bed. Despite these interventions being documented, they were not in place at the time of the incident. On the day of the incident, the resident experienced an unwitnessed fall from bed. Staff interviews and documentation revealed that the positioning wedges were not in use and were found on a chair or nightstand, the floor mat was not in place, and the bed was not at its lowest position. The resident was found on the floor, confused, with bleeding from the surgical incision and signs of injury. Staff confirmed that the care planned interventions were not followed, and the resident's confusion and restlessness were known risk factors that had been communicated to the facility by the family. Following the fall, the resident required emergency room treatment and hospital admission, where additional injuries including rib and pelvic fractures were identified. The failure to implement and maintain the prescribed fall prevention measures directly contributed to the resident's fall and subsequent injuries. Staff interviews confirmed a lack of adherence to the care plan and an inability to provide one-on-one supervision despite the resident's high risk status and family concerns.
Plan Of Correction
Element 1: Resident 102 no longer resides in the facility. Resident was discharged to the hospital on 12/15/25. Element 2: A one-time audit of current residents' fall interventions was completed by the Director of Nursing / Designee by 4/25/25 to ensure fall interventions are in place and reflect residents' current needs. Element 3: The QAPI Committee reviewed the Falls Clinical Protocol policy and deemed it appropriate by 4/25/25. The Director of Nursing and/or designee educated the Nurses and C.N.As on the Falls Clinical Protocol policy, with an emphasis on ensuring interventions are in place and that the interventions are noted on the incident reports. This education will be completed by 4/25/25. Element 4: The Director of Nursing/designee will audit 10 residents to ensure fall interventions are in place and will audit residents with falls to ensure that fall interventions in place at the time of the fall were documented on the incident report and that the care plan is updated with new interventions. These audits will be conducted weekly for 4 weeks, then monthly thereafter. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.