Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to establish and implement effective interventions to prevent falls and injuries for two residents with known fall risks. One resident with severe cognitive impairment and a history of multiple falls experienced repeated incidents involving wheelchair pedals. Despite documentation in the care plan and fall scene huddle worksheet that the resident had tripped on wheelchair pedals, staff did not consistently remove the pedals when not in use, as was indicated as a corrective action. This resident suffered multiple falls, including one that resulted in a head injury and subsequent admission to hospice care due to traumatic cerebral hemorrhage. Observations and staff interviews confirmed that the pedals were left on the wheelchair, and staff were not always able to supervise or intervene in time to prevent falls. Another resident with moderately impaired cognition and a history of falls, including fractures, experienced a fall that was not properly documented or investigated. The care plan lacked documentation of the fall and any new interventions following the incident. Progress notes described the fall and the resident's uncooperative behavior, but there was no incident report, falls tool assessment, or fall scene huddle worksheet completed for this event. The DON acknowledged that the fall was missed in documentation and that the incident was not fully assessed or followed up according to facility policy. Facility policy required prompt assessment, documentation, and investigation of falls, including completion of a fall scene huddle worksheet, falls tool, and care plan updates with new interventions. In both cases, the facility did not follow its own policy for fall prevention and management, resulting in missed opportunities to identify root causes and implement effective interventions to prevent further accidents.