Failure to Prevent Falls in Resident Receiving Psychotropic Medication
Penalty
Summary
The facility failed to identify and implement effective interventions to prevent further falls for a resident with dementia, limited safety awareness, and a known risk for falls. The resident was prescribed psychotropic medications, specifically Ativan, which was recently increased in dosage. Despite the resident's history and increased risk, the care plan contained only minimal fall interventions. The resident experienced multiple unwitnessed falls, including one resulting in head lacerations, and the facility's investigation did not consider the recent increase in Ativan dosage as a contributing factor. Subsequent documentation showed that the resident continued to have increased falls after the Ativan dose was raised, ultimately sustaining a fractured hip. Staff interviews confirmed that the Ativan contributed to the resident's falls and that the medication was not appropriate for the resident's needs. The decrease in Ativan dosage occurred only after the resident had already suffered a serious injury. The facility's lack of comprehensive assessment and timely intervention in response to the resident's changing condition and medication regimen led to repeated falls and significant harm.