Failure to Implement and Evaluate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, specifically in the implementation of its fall prevention program for a resident with multiple risk factors. The facility did not consistently conduct thorough investigations into the primary causes of the resident's falls, nor did it perform fall risk assessments after two of the resident's falls, as required by facility policy. Documentation was unclear or lacking regarding whether fall prevention devices, such as tab alarms and bed alarms, were properly applied or functioning at the time of the falls. Staff also did not consistently implement care plan interventions, such as ensuring alarms were in place and activated. The resident involved had significant cognitive and physical impairments, including dementia, Parkinson's disease, depression, anxiety, osteoarthritis, and movement disorders. She required substantial to maximal assistance with transfers and toileting and had no voluntary control over bowel and bladder functions. Despite being assessed as high risk for falls, the resident experienced four falls within a four-month period, one of which resulted in fractures to all five toes on her right foot. Observations and interviews revealed that the resident was able to unclip her tab alarm unassisted, and staff were aware of this but did not evaluate or implement alternative interventions. Interdisciplinary team (IDT) notes and interviews with facility leadership indicated that post-fall huddles and investigations were inconsistently documented and did not always address whether alarms were used or functioning. In some cases, staff presumed the cause of the fall without direct evidence, and there was no documentation of reminders to staff regarding the application of alarms. The facility's own policy required fall risk assessments after each fall, but these were not completed for at least two incidents. Only one root cause analysis was conducted for the resident's falls, despite multiple incidents.