Failure to Implement Fall Risk Communication Protocol
Penalty
Summary
The facility failed to follow its own Falling Star Program policy, which requires a star sticker to be placed on the door tag of any resident who has fallen within the last 30 days. Despite having fallen four times in the past four months and being assessed as high risk for falls, a resident did not have the required falling star sticker on their door post. Multiple observations confirmed the absence of the sticker, and staff interviews revealed that the lack of this indicator led to staff being unaware of the resident's fall risk status. As a result, staff did not provide the level of supervision or precautions that would have been indicated for a high fall risk resident. The resident involved had significant cognitive impairment, a history of dementia, and was dependent on staff for most activities of daily living. Documentation showed that the resident had experienced multiple falls and was consistently assessed as high risk for falls. However, the communication tool intended to alert staff to this risk—the falling star sticker—was not utilized as required by facility policy, leading to a lack of appropriate supervision and interventions.