Failure to Implement Adequate Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of appropriate assistance devices to prevent accidents for a resident with a history of multiple falls and significant cognitive impairment. The resident, an elderly female with diagnoses including dementia, diabetes, hypertension, and a history of fractures, experienced three falls—two unwitnessed and one witnessed—over a three-month period. Despite these incidents, the care plan did not include interventions such as fall mats or a low bed, and physician orders lacked fall precautions or increased monitoring. The only intervention added after the second fall was education and encouragement to use the call light for assistance, despite documentation and staff interviews indicating the resident was unable to use the call light appropriately due to severe cognitive impairment. Observations conducted over several days revealed that the resident's bed was not kept in the low position and no fall mats were present in her room, even after multiple falls. Staff interviews confirmed that prior to the most recent fall, interventions were limited to encouraging call light use and keeping the call light within reach. Both nursing and CNA staff expressed that the resident was not capable of using the call light effectively and that fall mats would have been an appropriate intervention given her fall history. Physical therapy assessments noted the resident's high fall risk and difficulty with transfers but did not recommend specific fall precautions or interventions. The facility's fall prevention policy requires that all residents at high risk for falls have individualized care plans with appropriate interventions, yet this was not followed for the resident in question. The incident log lacked detailed outcomes for the falls, and the care plan was not updated with effective interventions after repeated incidents. The lack of timely and appropriate fall prevention measures contributed to the resident experiencing multiple falls, including one resulting in a hip fracture.