Failure to Assess and Implement Timely Fall Interventions
Penalty
Summary
The facility failed to comprehensively assess and implement timely interventions following a resident's fall. The resident, who had moderate cognitive impairment and diagnoses including dementia, depression, osteoporosis, and neurogenic bladder, had a documented history of falls and was identified as a high fall risk. Despite this, the care plan only included basic interventions such as bed and chair alarms, and lacked additional measures to protect the resident from further falls. After the resident was found on the floor following an attempted self-transfer, documentation did not include a thorough investigation into contributing factors such as last toileting, footwear, call light availability, or when the resident was last seen. No new interventions were added to the care plan after the fall, and the post-fall documentation and root cause analysis were incomplete. Interviews with staff revealed inconsistent practices regarding frequent checks after falls, with unclear documentation and implementation. The nurse assistant and LPN described procedures for frequent checks, but records showed these were not consistently started or documented for the resident in question. The RN acknowledged missing information in the fall investigation and admitted to copying previous documentation without conducting a comprehensive review or initiating frequent checks. The DON confirmed that a complete investigation and root cause analysis should have been performed, and interventions should have been care planned based on findings, which did not occur in this case.