Failure to Implement and Update Fall Interventions for Residents
Penalty
Summary
The facility failed to ensure that two residents remained as free from accident hazards as possible by not implementing appropriate or new interventions after each fall. For one resident with severe cognitive impairment and multiple comorbidities, including dementia and heart failure, the care plan did not include interventions for all documented falls, and the intervention that was implemented—reminding the resident to call for assistance—was not appropriate given the resident's cognitive status. Additionally, two subsequent falls were not addressed with any new interventions or updates to the care plan. Another resident, who had intact cognition but was at risk for falls and required assistance with activities of daily living, experienced a fall that was not addressed in the care plan, and there was no documented evidence that any intervention was attempted after the incident. The Director of Nursing confirmed that new interventions were not implemented for either resident following their respective falls, and that the care plans were not updated to reflect these incidents.