Failure to Implement Fall Interventions and Notify Guardian of Medication Refusals
Penalty
Summary
Surveyors identified that the facility failed to implement care-planned fall interventions for a resident at risk for falls. The resident had a documented history of falls, with interventions such as a fall mat and 'Call Don't Fall' signage ordered and care planned after previous incidents. However, during multiple observations, neither the fall mat nor the signage was present in the resident's room. Both the LPN and the Director of Nursing confirmed the absence of these interventions during interviews, despite facility policy requiring their implementation and staff in-servicing. Additionally, the facility did not consistently notify the resident's court-appointed guardian when the resident refused ordered medications more than two times in a row, as specifically requested by the guardian. The resident, who was cognitively intact but adjudged incapacitated and had a guardian, refused a significant number of doses of multiple critical medications over several months, including those for diabetes, hypertension, depression, and nerve pain. Facility policy required notification of the guardian and assessment of reasons for refusal, but documentation did not show consistent guardian notification or assessment of refusal causes such as dry mouth or swallowing difficulty. Interviews with the APRN, DON, and Administrator confirmed that the expectation was for the guardian to be notified with each medication refusal, especially after the guardian's explicit request. However, the DON was unable to provide documentation that this occurred, and the guardian reported only being notified on two occasions despite frequent refusals. The lack of consistent implementation of fall interventions and failure to notify the guardian of medication refusals as required by policy and the guardian's request led to the identified deficiencies.