Failure to Implement and Document Fall Prevention Interventions After Resident Falls
Penalty
Summary
The facility failed to investigate, determine causative factors, and implement relevant interventions to prevent further falls for a resident with severe cognitive impairment and multiple medical conditions, including Lewy body dementia, brain neoplasms, reduced mobility, and a history of stroke. The resident was dependent on staff for bed mobility, transfers, and toileting, and used a wheelchair. Despite being identified as at risk for falls due to deconditioning, gait, and balance problems, the care plan did not include additional fall interventions after the resident was found lying face down on the floor at the bedside following a fall. After the initial fall, staff assessed the resident, found no visible injuries, and sent her to the hospital for evaluation. The only intervention documented in response to this fall was the hospital evaluation; no further fall prevention measures, such as floor mats or bolstered mattresses, were implemented at that time. The facility did not conduct a thorough investigation or root cause analysis beyond noting that the resident did not know what happened and had rolled out of bed. There was no evidence of additional interventions being added to the care plan following this incident. Subsequently, the resident experienced another unwitnessed fall from bed, resulting in a left femur fracture. Staff again assessed the resident, provided pain management, and sent her to the hospital after continued complaints of pain. Only after this second fall were interventions such as a bolstered mattress and fall mat put in place. Interviews with facility staff confirmed that no additional fall interventions were added after the first fall, and there was no documented investigation or comprehensive review of the incident. The facility's policy required staff to identify and implement interventions based on specific risks and causes, but this was not followed after the initial fall.