Failure to Implement and Communicate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that progressive fall interventions were implemented and that staff were aware of these interventions for a resident identified as high risk for falls. The resident, who had diagnoses including diabetes mellitus, cerebral infarction, hypotension, dementia, and gait abnormalities, was severely cognitively impaired, used a wheelchair, and required partial assistance with walking. Despite being care planned as a fall risk and having a history of falls, interventions such as ensuring the resident wore grippy socks and the addition of a non-slip mat to the wheelchair were not consistently in place. On observation, the resident was found wearing regular socks without grips, and staff members interviewed were unaware of the requirement for grippy socks or the use of a non-slip mat. The resident experienced multiple falls, including one that resulted in a laceration, hematoma, and skin tears, requiring emergency room evaluation. Documentation showed that after each fall, interventions were updated in the care plan, but these were not effectively communicated or implemented by staff. Interviews with CNAs revealed a lack of awareness regarding the specific fall prevention measures, indicating a breakdown in communication and execution of the care plan interventions designed to prevent further accidents.