Failure to Review and Update Fall Interventions After Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and services to prevent accidents for one resident reviewed for falls. Specifically, after a resident experienced a fall in the main courtyard, there was no documentation that a root cause analysis was conducted by the nurse on duty or by the interdisciplinary care team (IDT). The facility's policy requires that after a fall, the IDT analyze the incident to identify specific accident hazards or risks and target interventions to reduce those risks, but this process was not followed in this case. The resident involved was over 65 years old with multiple diagnoses, including dementia, diabetes, COPD, and chronic kidney disease, and had a history of falls. The resident required varying levels of assistance for mobility and activities of daily living and used a manual wheelchair. Despite these risk factors, the resident's fall care plan had not been updated since the previous year, and there was no evidence that the care plan was reviewed or revised following the fall incident. Additionally, the weekly nurse summary note failed to document the fall, and there was no further progress note detailing the incident or any follow-up. Interviews with facility leadership revealed that the DON and regional clinical resource were unaware of the fall, as it had not been entered into the risk management system by the nurse on duty, who was an agency nurse. As a result, the required IDT meeting to determine the root cause and review the effectiveness of fall interventions did not occur. The lack of documentation and communication prevented the facility from implementing or modifying interventions to prevent future falls for this resident.