Failure to Update Fall Interventions After Resident Falls
Penalty
Summary
A resident with multiple medical conditions, including muscle weakness, unsteadiness, reduced mobility, cellulitis, end stage renal disease, and a need for assistance with personal care, was admitted to the facility and identified as a high fall risk based on an initial Fall Risk Evaluation. Despite this high risk, the resident experienced two falls: one unwitnessed fall in her room and a second witnessed fall while transferring into bed. Following both incidents, the resident's Fall Risk Care Plan, which initially included only standard admitting interventions, was not updated to reflect the new falls or to add individualized interventions. The facility's Fall Prevention policy requires that safety interventions be added to the care plan for residents at risk for falls and that interventions be individualized. However, no changes or additions were made to the care plan after either fall, as confirmed by record review and staff interview.