Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate safety measures for a resident with a history of falls and traumatic brain injury. The resident, who was admitted from the hospital after a fall resulting in a brain bleed, also had multiple diagnoses including pneumonia, difficulty walking, lack of coordination, COPD, diabetes, congestive heart failure, hypertension, and kidney failure. Despite the resident's known fall risk and a recent fall within the facility, no new fall interventions were put in place after the incident. Family members expressed concern that no visible safety devices or interventions had been added, and staff interviews confirmed that no updates were made to the resident's care plan or interventions following the fall. Observations revealed that the resident's bed was left in an elevated position with his feet hanging off the side, and staff needed to be called to reposition him safely. Staff members, including CNAs and RNs, were unaware of any new fall interventions and did not reference a care card for safety measures. The DON acknowledged that the resident's prior fall history should have been included in the initial assessment and that interventions such as keeping the bed in a low position and offering assistance after meals were not consistently implemented. Facility policies required assessment and intervention after each fall, but these were not followed for this resident.