Failure to Implement Effective Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to implement effective, individualized fall prevention interventions for residents identified as high risk for falls, particularly those with severe cognitive impairment and poor safety awareness. One resident with hemiplegia, muscle weakness, abnormal gait, and a history of falls experienced multiple incidents of self-transfer attempts resulting in falls. Despite being care planned for high fall risk, the resident was observed wearing regular socks instead of non-skid socks and was able to access and wear an AFO brace independently, contrary to staff instructions that it should only be used at night. Staff confirmed that the resident required minimal assistance with transfers and that the AFO brace was being kept in a drawer to prevent unsupervised use, but the resident had previously been able to put it on without supervision. Another resident with a history of falls, dementia, and wandering behavior was also identified as high risk for falls. This resident was found on the floor near a stairwell exit door after a fall, having sustained a fracture of the left humerus. The resident had a baseline of wandering and confusion, often requiring redirection to find her room or bathroom. Staff interviews confirmed that the resident was typically monitored in the dining room for safety, but on the day of the incident, she was able to access the exit door, which had an alarm and a delayed opening mechanism. The resident was found on the stairs with her wheelchair nearby, and staff responded to the alarm after the fall had already occurred. The facility's fall prevention and management policy required identification and evaluation of residents at risk for falls, with care plans updated and interventions implemented based on root cause analysis after each fall. However, the care plans and interventions in place for these high-risk residents were not sufficiently individualized or effectively implemented to prevent repeated falls and injuries, as evidenced by the incidents described and staff observations regarding supervision, use of safety equipment, and monitoring of wandering behaviors.