Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement and maintain fall prevention interventions for a resident with multiple risk factors, including dementia, agitation, delusional disorders, impaired decision-making, and frequent incontinence. The resident's care plan and bedside Kardex included several fall prevention measures such as visible signage, hourly toileting, non-slip strips in key areas, 15-minute safety checks, and assistance with transfers. Despite these documented interventions, observations and record reviews revealed that many of these measures were not in place or not consistently implemented. For example, non-slip strips were missing from the bathroom and recliner, the 'Call Don't Fall' sign was not visible, and non-slip material was absent from the wheelchair and recliner seats. Additionally, the resident's room was not moved closer to the nurse's station as planned, and required safety checks and hourly toileting were not documented or observed during the survey period. The resident experienced multiple falls over a three-month period, with documented incidents occurring in various locations such as in front of the recliner and in the bathroom. Progress notes indicated that the resident often attempted to move independently, including trying to use the toilet or brush teeth, which led to falls. Staff interviews confirmed that required 15-minute safety checks were not accurately documented or performed, and that interventions such as non-slip strips and materials were not consistently maintained. The resident also had a change in condition, including pitting edema and a diagnosis of hyponatremia, which was not fully addressed due to a missed blood test order that was neither completed nor followed up with the provider. Facility policy required thorough investigation of all falls, evaluation for changes in condition, provider notification, and implementation of new interventions as needed. However, the facility did not ensure that these protocols were followed, as evidenced by the lack of documentation, incomplete implementation of care plan interventions, and failure to complete ordered diagnostic tests. These lapses contributed to the resident's repeated falls and unaddressed changes in medical condition.