Failure to Update Fall Prevention Interventions and Care Plan
Penalty
Summary
The facility failed to identify and implement appropriate interventions to prevent falls for a resident with a history of repeated falls and multiple risk factors, including impaired mobility, moderately impaired cognition, and use of medications such as antianxiety agents, antidepressants, diuretics, and opioids. The resident's care plan documented the risk for falls and included interventions such as reminding the resident to notify staff when not feeling well, applying non-skid strips at the bedside, answering the call light promptly, and ensuring the resident wore nonskid socks and footwear during transfers and walking. However, after documented falls, the care plan and electronic medical record were not updated with new interventions to address the ongoing risk. The resident experienced multiple falls, including one incident where the resident slid off the bed while reaching for a television remote and another where the resident slid down in the bathroom while wearing shoes with no tread. Observations revealed the absence of non-skid strips at the bedside, and staff interviews indicated that interventions following falls were not consistently documented or updated in the care plan. Additionally, the facility was unable to provide a fall management program policy upon request.