Failure to Implement Fall Interventions, Complete Root Cause Analyses, and Assess Elopement and Swallowing Risks
Penalty
Summary
The facility failed to ensure that interventions were implemented and root cause analyses were completed following falls for two residents, resulting in actual harm. One resident with severe cognitive impairment, Alzheimer's disease, and osteoporosis experienced two unwitnessed falls. The first fall occurred when the resident slid out of bed, with improper footwear identified as a predisposing factor. Although a perimeter mattress was implemented, the intervention for gripper socks was not added to the care plan or consistently documented as refused. The resident later suffered a second fall, again slipping on socks, resulting in a right femur fracture that required surgical intervention. Observations revealed that staff did not consistently provide the required supervision or follow care plan interventions, such as using a walker, transfer belt, or wheelchair during ambulation, and did not ensure proper footwear. Another resident with multiple comorbidities, including COPD, CHF, and a history of falls, experienced two unwitnessed falls in the bathroom, resulting in a head laceration and a fractured clavicle. After the first fall, there was no documentation of a root cause analysis or new interventions added to the care plan, despite facility policy requiring such actions. The only intervention following the second fall was a referral to physical and occupational therapy. Interviews with staff confirmed that root cause analyses and care plan updates were not consistently completed after falls, and there was a lack of clarity on how to determine the resident's safety for independent transfers and toileting after such incidents. The facility also failed to complete an elopement risk assessment for a resident who attempted to leave the facility without supervision, despite policy requiring such assessments upon admission. Additionally, a resident with reported coughing during meals was not monitored while eating in their room, and the care plan and Kardex lacked information about swallowing difficulties or the need for supervision. Staff interviews revealed inconsistent understanding and documentation of monitoring requirements for residents with potential swallowing issues, and there was no evidence that the provider was updated or that a risk versus benefit assessment was completed for eating in the room.