Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for three residents, resulting in falls and injuries. One resident with a history of falls, severe cognitive impairment, and multiple comorbidities experienced an unwitnessed fall while attempting to use the bathroom. At the time of the fall, required interventions such as a bed alarm, fall mat, and accessible call light were not in place, despite being documented in the care plan. The resident sustained a right femoral fracture and a laceration to the right temporal lobe, requiring emergency medical treatment and resulting in significant pain and a decline in condition. Staff interviews confirmed that fall interventions were not consistently implemented, and it was common practice for night shift staff to partially dress residents to expedite morning routines, which contributed to the incident. Two additional residents with histories of falls and cognitive or mobility impairments did not receive timely fall risk assessments as required by facility policy. Documentation showed that fall risk assessments were not completed after multiple falls or at required intervals. For one resident, the wheelchair alarm was not functioning at the time of a fall, and there were no documented interventions or orders to ensure the alarm was routinely checked. Another resident, identified as high risk for falls, was not wearing non-skid socks as specified in the care plan, and staff confirmed this intervention was not in place at the time of observation. The facility's fall prevention policy required individualized assessments and the implementation of appropriate interventions, including supervision and assistive devices. However, observations, interviews, and record reviews demonstrated that these measures were not consistently followed. Staff were not always aware of or did not implement care plan interventions, and required assessments were missed after falls and significant changes in condition. These failures resulted in preventable falls and injuries among residents at risk.