Failure to Implement and Maintain Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain effective fall prevention interventions for multiple residents identified as high risk for falls. For one resident with a history of falls, head injury, dementia, and significant physical limitations, the care plan included interventions such as floor mats, bed/chair alarms, and keeping personal items within reach. Despite these interventions, the resident experienced multiple falls, including incidents where she was found on the floor after attempting to access the phone or bathroom without assistance. After one such fall, the resident sustained a cervical neck fracture and facial abrasions, requiring emergency hospital transfer. Interviews with staff revealed that after repeated falls, no new interventions were added to the care plan, and only minor adjustments were made to existing interventions. Another resident with severe cognitive impairment, a history of falls, and physical limitations also experienced repeated falls, including one resulting in a head laceration that required staples. The care plan for this resident included frequent monitoring, use of floor mats, and virtual sense technology (VST) for alerting staff to movement. However, during one incident, the assigned CNA did not have the required alert tablet with her, leaving the resident unsupervised and resulting in a fall with significant injury. Staff interviews confirmed that the expected supervision and monitoring protocols were not consistently followed, and the resident was able to move unsupervised from a common area to her room, where the fall occurred. A third resident, also at high risk for falls due to dementia, weakness, and a history of fractures, was observed without all required fall prevention interventions in place. The resident was found sleeping in a bed that was not in the lowest position, with only one floor mat in place instead of the required mats on both sides. Additionally, the VST monitor intended to alert staff to movement was not present in the room, and the assigned CNA was unaware of its location. Staff interviews indicated that frequent checks were not documented, and the required interventions were not consistently implemented or monitored. These failures resulted in repeated falls and inadequate supervision for residents at high risk.