Failure to Conduct Required IDT Meetings and Accurate Fall Risk Assessments After Multiple Falls
Penalty
Summary
The facility failed to implement its Fall Management Program policy and procedure by not conducting and initiating an Interdisciplinary Team (IDT) meeting after each of three falls sustained by a resident. The policy required the IDT to review and update the resident's fall risk status and care plan upon identification of a significant change of condition post-fall. Despite this requirement, the IDT meetings were not held after each fall, as acknowledged by the Director of Nursing (DON), and the care plan was not appropriately updated to address the resident's ongoing fall risk. The resident involved had a history of muscle weakness, abnormal gait, mobility issues, and alcoholic cirrhosis. Upon admission, the resident was identified as high risk for falls, with a fall risk score of 19.0, and required moderate assistance with activities of daily living. The resident experienced three falls within a short period, each documented in the medical record. After each fall, care plans were updated with interventions such as neuro checks, floor mats, and physical therapy consults, but the required IDT meetings to review the circumstances and revise the care plan were not conducted. Additionally, there were inaccuracies in the documentation of the resident's fall risk scores following each incident, with the scores decreasing despite repeated falls. The DON confirmed that these inaccuracies were due to incorrect information entered into the computer system. The failure to conduct IDT meetings and maintain accurate fall risk assessments resulted in the resident continuing to experience falls, with the potential for life-threatening injuries.