Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident with a known history of falls and significant cognitive impairment. Upon admission, the resident was assessed as high risk for falls due to diagnoses including nontraumatic subarachnoid hemorrhage, Lewy body dementia, depression, and a previous traumatic subdural hemorrhage. Despite this, the baseline care plan did not include any fall interventions, and the comprehensive care plan was not updated with fall interventions until several days after admission. The resident experienced multiple unwitnessed falls within the facility shortly after admission, yet no individualized fall interventions or safety measures were implemented following these incidents. Interviews with the resident's Power of Attorney for Healthcare (POAHC) and the Director of Nursing (DON) confirmed that fall interventions were not added to the care plan upon admission or after the initial falls. The DON acknowledged that 15-minute checks were conducted as a standard practice for new admissions but were not individualized fall interventions. The facility's own Fall Reduction Policy required individualized interventions and care plan updates after each fall, which were not followed in this case.