Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for three residents identified as being at risk for falls. One resident, with a history of traumatic brain injury, paraplegia, and severely impaired cognition, was assessed as high risk for falls but did not have a care plan addressing this risk. After being placed on a low air loss mattress, the resident experienced an unwitnessed fall resulting in a cervical vertebra fracture, with documentation showing no interventions were implemented to prevent falls following the mattress change. Another resident, diagnosed with cerebral palsy and severely impaired cognition, experienced two unwitnessed falls. After the first fall, the only intervention documented was sending the resident to the ER for evaluation, with no additional fall prevention measures developed. Following the second fall, interventions were limited to medication review and behavioral assessment notifications, again without specific fall prevention strategies being added to the care plan. A third resident, with end stage renal disease and multiple comorbidities, fell from her wheelchair while attempting to reach a wall and was subsequently assessed as high risk for falls. However, the care plan was not updated to address the fall, and no new interventions were implemented. Observations revealed that residents at high risk for falls did not have fall mats in place, and beds were not maintained in the lowest position, further indicating a lack of effective fall prevention measures.
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. These conversations are considered part of the QA process.
- 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 was initially implemented and will be monitored through completion by corporate and regional staff.
- Plan of Removal completion with continuation of oncoming staff and follow-up.