Failure to Implement and Communicate Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement resident-centered care plan interventions for fall prevention for two residents with known fall risks. One resident, who was legally blind, hard of hearing, and had dementia, experienced multiple unwitnessed falls, including falling out of bed and later from a wheelchair in the hallway. Despite care plan interventions such as non-skid footwear, staff assistance with transfers, and the use of a bolster mattress, these measures were not consistently implemented. The resident was found wearing regular socks instead of non-skid footwear and was placed in a wheelchair in the hallway for supervision after a fall, but was left unattended while staff attended to other residents. This resulted in a second fall, causing a head laceration that required emergency medical treatment and sutures. Another resident, with severe cognitive impairment and a history of falls and hip fractures, also experienced a fall resulting in a major injury. The care plan for this resident included interventions such as keeping the call light within reach, staff assistance with transfers, and ensuring the floor was free of hazards. However, the resident was found on the floor in their room, undressed, and without staff present. The resident's family expressed concerns about the lack of monitoring and the unclear circumstances surrounding the fall. Documentation indicated that the resident was unable to use the call light due to cognitive impairment, and staff did not provide adequate supervision or implement all care plan interventions, such as the use of a winged mattress to help define space. Interviews with staff and family members revealed gaps in staff awareness and execution of planned interventions. Staff were unable to explain why certain interventions, such as non-skid footwear and bolster mattresses, were not in place at the time of the falls. Additionally, staffing levels and assignments contributed to periods when high-risk residents were left unsupervised. The lack of consistent implementation of individualized fall prevention strategies and insufficient supervision directly led to residents experiencing preventable falls with injury.