Failure to Implement Effective Fall Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement effective fall interventions tailored to the root cause for a resident with multiple falls. The resident, who had diagnoses including Parkinson's disease, functional quadriplegia, difficulty in walking, and orthostatic hypotension, experienced six falls over a six-month period. Despite being identified as a high fall risk, the interventions added after each fall were largely repetitive and did not address the underlying causes of the falls, such as the resident's attempts to self-transfer or refusal to use the call light for assistance. Documentation revealed that after each fall, interventions such as encouraging the use of the call light, keeping the environment safe, and providing education were repeated, even though the resident continued to fall in similar circumstances. There was no evidence of new or different interventions being implemented after repeated falls of the same nature. Staff interviews confirmed that interventions were often repeated, and there was a lack of clarity among staff regarding how fall interventions were chosen or evaluated for effectiveness. Some staff were unable to recall what interventions were put in place after specific falls, and there was no documentation of reassessment or modification of interventions when falls recurred. The facility's policy required that interventions be individualized and adjusted if falls recurred, and that staff monitor and document the effectiveness of interventions. However, the report shows that the same interventions were used multiple times without documented assessment of their effectiveness or consideration of alternative strategies. The resident's continued decline and repeated falls, despite these interventions, indicate that the facility did not adequately address the root causes of the falls as required by their own policy.