Failure to Implement Timely Fall Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement timely and appropriate fall interventions for a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including dementia, muscle weakness, and unsteadiness, experienced multiple unwitnessed falls over several months. After an initial fall, the only intervention added was to have the resident seen by a primary care physician, which did not occur until after a subsequent fall. No additional fall prevention measures were implemented between the first and second falls, despite the resident's inability to comprehend or use a call light and a care plan indicating the need for two-person assistance and mechanical lift for transfers. Further review showed that after each fall, interventions were added to the care plan, such as scheduled toileting and reminders not to self-transfer, but these were not implemented in a timely manner to prevent repeat incidents. The DON confirmed that no other interventions were put in place after the initial fall and acknowledged that additional measures should have been taken to reduce the risk of further falls. The lack of prompt and adequate intervention contributed to the resident experiencing repeated falls.