Failure to Update Fall Risk Interventions Leads to Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate, individualized, and effective fall risk interventions for a resident identified as high risk for falls. The resident, who had multiple diagnoses including atrial fibrillation, anxiety disorder, morbid obesity, and acute kidney failure, was admitted to hospice care and was receiving medications such as morphine and Ativan. Despite being assessed as high risk for falls on admission, no further fall risk assessments were completed until after the resident experienced a fall with injury. The resident's care plan, which initially included fall risk interventions, was not updated to reflect changes in her condition or behaviors that increased her fall risk. Prior to the incident, the resident exhibited terminal agitation, including attempts to get out of bed and remove her clothing. Staff and family members observed these behaviors, and hospice staff recommended keeping the bed in the lowest position. However, on the night of the incident, the resident was found on the floor with her bed in a high position, having sustained a fractured left arm, a laceration to her forehead, and a bruise to her cheek. The bed remote, which controlled the bed's height, was found on the floor next to the resident. There was conflicting information regarding whether staff had entered the room to adjust the bed or provide care prior to the fall. Interviews with facility staff, the administrator, and the DON confirmed that the resident's fall prevention interventions and risk assessments had not been updated since admission, despite her ongoing risk factors and recent behavioral changes. The facility's policy required staff to implement resident-centered fall prevention plans based on current evaluations and data, but this was not done for the resident prior to her fall and injury. The lack of updated assessments and interventions directly contributed to the resident's unwitnessed fall and subsequent harm.