Failure to Analyze and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to conduct thorough root cause analyses of falls and did not consistently implement or document fall prevention interventions as care planned for three residents. For one resident with Alzheimer's disease and severe cognitive impairment, multiple falls occurred, some unwitnessed, with the clinical record lacking detailed interdisciplinary team (IDT) notes for certain incidents. The IDT's root cause analyses were limited to describing the circumstances in which the resident was found, without deeper investigation into underlying causes. Interventions such as offering naps and assessing footwear were noted, but the documentation did not reflect a comprehensive analysis using the facility's own '5 Whys' policy, as required. Another resident with Parkinson's disease, a history of repeated falls, and orthostatic hypotension experienced several unwitnessed falls resulting in injuries. The care plan included the use of hip protectors, but there was no evidence in the electronic health record that staff consistently offered or documented the resident's use or refusal of the hip protectors. Interviews revealed that the resident had not worn the hip protectors and staff were unsure of their location or whether they had been offered, indicating a lack of follow-through on the care plan interventions and documentation requirements. A third resident, dependent on staff for transfers and with a history of stroke and unsteadiness, was care planned to have bed bolsters added for fall prevention after an unwitnessed fall. Observations on multiple occasions showed that bed bolsters were not present on the resident's bed, and there was conflicting information regarding whether the resident had refused them. The care plan was updated to indicate refusal, but there was no supporting documentation in the electronic health record, and the resident's representative reported that staff had not returned to install the bolsters after an initial attempt. These findings demonstrate failures in both implementing and documenting individualized fall prevention interventions as required by facility policy.