Failure to Implement and Document Fall Prevention Protocols for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls were adequately supervised and protected from accident hazards, as evidenced by repeated failures to follow fall protocols, update care plans, and implement or maintain fall prevention interventions. Both residents had extensive histories of falls, with one resident experiencing 23 falls and the other 34 falls within a year. Despite documented high fall risk and multiple interventions listed in their care plans, there were numerous instances where interventions were not in place, such as call lights not being within reach, lack of non-skid footwear, and absence of required safety equipment like dycem or non-skid strips. Observations also revealed that residents were left unattended in their rooms, contrary to care plan instructions. The clinical records for both residents showed significant gaps in documentation and follow-through after falls. Many falls lacked Interdisciplinary Team (IDT) notes, timely updates to care plans with new interventions, and completion of fall risk assessments. In several cases, there was no evidence that the physician or responsible party was notified after a fall, and some falls were only referenced in 72-hour charting notes without details on the circumstances or follow-up. Additionally, some interventions added to care plans after IDT reviews were not observed to be implemented during surveyor observations. Both residents had complex medical histories, including dementia, muscle weakness, repeated falls, and other comorbidities that increased their vulnerability. Despite these risks, the facility did not consistently anticipate or meet their needs, failed to ensure prompt response to call lights, and did not always provide appropriate supervision or assistance with toileting and transfers. The lack of consistent documentation, communication, and implementation of fall prevention strategies contributed to ongoing falls and injuries for these residents.