Failure to Implement and Communicate Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for two residents with known high fall risk, resulting in repeated falls and injury. One resident, with diagnoses including dementia, repeated falls, and severe cognitive impairment, experienced multiple falls over a period of time. Despite a care plan outlining numerous fall prevention interventions such as safety checks, anti-tippers for the wheelchair, non-skid footwear, and floor mats, these interventions were inconsistently implemented. After each fall, there was a lack of immediate new interventions to prevent further incidents, and required equipment such as anti-tippers and floor mats were often missing or on backorder. The resident sustained injuries including a left ankle fracture and a gash to the face, with documentation showing that staff and interdisciplinary team meetings did not result in timely or effective changes to the care plan or its implementation. Another resident, also with severe cognitive impairment and multiple comorbidities, was similarly identified as a high fall risk. The care plan for this resident included interventions such as anti-rollbacks for the wheelchair, floor mats, and non-skid strips. However, observations revealed that these interventions were not in place at the time of survey, and the resident experienced several falls, often found on the floor without the prescribed safety equipment. Staff interviews indicated confusion about who was responsible for implementing new interventions, and communication about fall interventions was inconsistent. Maintenance was sometimes responsible for installing equipment, but there was no clear process to ensure timely implementation. Throughout the report, staff interviews and observations highlighted a lack of awareness and understanding of the residents' fall interventions among CNAs, LPNs, and other staff. Communication about changes to care plans and interventions was primarily verbal during shift changes or huddles, and documentation was not always updated promptly. The facility's failure to ensure that fall prevention interventions were consistently implemented and that staff were adequately informed and trained contributed directly to repeated falls and injuries for residents at high risk.