Failure to Document Falls and Implement Timely Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure that falls were properly documented, appropriate interventions were implemented, and a call light was kept within reach for a resident with a history of falls. During observation, the resident was found in a recliner without the call light accessible, and the resident confirmed he could not use it when needed. The resident had a history of multiple falls, both witnessed and unwitnessed, some resulting in injuries such as skin tears and a possible wrist fracture. Despite these incidents, documentation in the Progress Notes was incomplete or missing for several falls, and immediate post-fall assessments or new interventions were not consistently recorded. The resident's medical history included generalized muscle weakness, a history of falling, and a previous wrist fracture. The care plan indicated the resident was at risk for falls and listed interventions such as keeping the bed in the lowest position, using a floor mat, providing two staff for assistance with activities of daily living, and ensuring the call light was within reach. However, these interventions were not always implemented or communicated effectively to staff. For example, the call light was not within reach during observation, and a CNA was unaware of specific interventions related to the resident's recliner or recent falls. Interviews with the DON and staff revealed that falls were supposed to be documented in both Progress Notes and internal Risk Management documents, and that interventions should be initiated at the time of each fall. However, the record review showed gaps in documentation and a lack of timely intervention implementation. The facility's policy required assessment and individualized interventions after each fall, but this was not consistently followed, leading to the deficiency.