Delayed Implementation of Fall Interventions Following Multiple Resident Falls
Penalty
Summary
The facility failed to ensure timely implementation of person-centered fall interventions for a resident identified as high risk for falls. Despite having a policy that required the interdisciplinary team to review falls and implement interventions promptly, there were repeated delays in putting fall prevention measures in place after each incident. The resident, who had Parkinson's disease, gait and balance issues, and required assistance with transfers, experienced multiple unwitnessed and witnessed falls over several months. In each case, specific interventions such as reminders to lock wheelchair brakes, ensuring frequently used items were within reach, and physical therapy evaluations were not implemented until several days to over a month after the falls occurred. The resident reported frequent falls due to long wait times for staff assistance and a lack of fall interventions. Record review confirmed that interventions were consistently delayed, with some not implemented until after subsequent falls had already occurred. Staff interviews corroborated that interventions should have been implemented more promptly to prevent further incidents, but this did not happen, resulting in the resident remaining at risk for additional falls during the periods of delay.