Failure to Implement Adequate Fall Prevention Interventions
Penalty
Summary
The facility failed to implement adequate interventions and supervision to prevent multiple falls for a resident with severe cognitive impairment and a history of impulsive behaviors. The resident, who was non-interviewable due to cognitive impairment and had diagnoses including metabolic encephalopathy, seizure disorder, muscle weakness, bipolar disorder, and impulse disorder, experienced numerous falls resulting in injuries and hospital visits. Observations showed the resident attempting to self-propel in a wheelchair and resist redirection from staff, while interviews with the roommate confirmed frequent nighttime activity and falls. Review of the resident's care plan and medical records revealed repeated falls, some resulting in significant injuries such as lacerations requiring stitches and multiple hospital transfers. Despite these incidents, there was a lack of consistent and timely updates to the fall care plan following several falls. The care plan included interventions such as keeping the resident in common areas when awake, providing structured activities, ensuring a hazard-free room, using a mat next to the bed, and a low bed, but these interventions were not consistently revised or augmented after repeated falls. Staff interviews indicated a lack of interventions specifically targeted for nighttime, when many of the falls occurred. The Unit Manager acknowledged the absence of nighttime activities or interventions and suggested that such measures might have helped reduce the number of falls. Additionally, there was no documented follow-up on recommendations for additional safety equipment, such as bed bolsters, and the facility's fall prevention policy requiring assessment and care plan revision was not consistently followed.