Failure to Develop and Implement Comprehensive Fall Prevention Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents identified as high risk for falls. For three residents reviewed, the care plans did not address their assessed fall risks or include specific interventions to prevent falls or injuries. In one case, a male resident with a history of traumatic brain injury, paraplegia, and impaired cognition was assessed as high risk for falls, but his care plan did not include fall prevention interventions. After being placed on a low air loss mattress, there was no documentation of additional fall prevention measures, and the resident subsequently experienced an unwitnessed fall resulting in a cervical vertebra fracture and required hospitalization. Another resident, a female with cerebral palsy, schizoaffective disorder, and severely impaired cognition, experienced two unwitnessed falls. Despite being identified as high risk for falls after the first incident, her care plan only included sending her to the ER for evaluation and did not add further fall prevention interventions. After the second fall, the care plan was updated to include medication review and behavioral assessment, but again lacked specific interventions to prevent future falls. A third resident, a female with end stage renal disease, diabetes, and bipolar disorder, was not initially identified as high risk for falls but experienced a fall while in her wheelchair. Following the incident, her fall risk assessment was updated to high risk, but her care plan was only revised to include bed rails for safety, without addressing the fall event or implementing additional fall prevention strategies. Interviews with facility staff confirmed that care plans were not consistently updated to reflect residents' fall risks or incidents, and that interventions were not always implemented as required by facility policy.
Removal Plan
- Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.
- The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention.
- Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides.
- The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall.
- MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions.
- Administrator and DON were in-serviced by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions.
- If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.
- The Medical Director was made aware of the Immediate Jeopardy and has been involved in developing the Plan of Removal.
- A QAPI meeting was held with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer.
- This plan will be monitored through completion by corporate and regional staff.
- Plan of Removal completion with continuation of oncoming staff and follow-up.