Failure to Implement Fall Prevention Interventions During Resident Appointments
Penalty
Summary
A deficiency occurred when the facility failed to ensure that fall interventions were followed for a resident identified as being at risk for falls. The resident, who had diagnoses including congestive heart disease, muscle weakness, and post-traumatic stress disorder, returned from an outside appointment and reported to staff that she had fallen in the bathroom during the appointment, resulting in an open and closed distal fracture of her left wrist. Although the care plan, updated after the incident, specified that staff were to accompany the resident to all outside appointments, documentation and interviews confirmed that this intervention was not implemented for a subsequent appointment. Specifically, the resident was transported to a follow-up appointment by the Maintenance Director without any staff accompanying her, contrary to the care plan intervention. Interviews with facility staff, including the Administrator, Maintenance Director, and LPNs, revealed a lack of communication and awareness regarding the requirement for staff accompaniment. The Maintenance Director stated he was not notified that the resident required accompaniment until after the second appointment had already occurred. The facility's fall prevention policy required that new interventions be implemented and care plans updated to prevent further falls, but the intervention to accompany the resident was not followed.