Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to implement individualized interventions and provide adequate supervision to prevent avoidable falls for a resident with multiple risk factors, including cerebral infarction, muscle wasting, impaired mobility, and cognitive deficits. The resident experienced four falls over a short period, each time attempting to go to the bathroom independently. Despite being identified as at risk for falls and having care plans that included interventions such as keeping the call light within reach, encouraging use of the call light, providing lateral fall pads, and ensuring a safe environment, documentation showed inconsistent implementation of these interventions. There was also conflicting information regarding the resident's continence status and the frequency of toileting assistance provided. The facility's records lacked evidence that staff consistently provided timely incontinent care or regular toileting, particularly in the hours leading up to the falls. After each fall, care plans were updated with additional interventions, such as posting signs to remind the resident to call for help, using nonskid footwear, and checking the resident every 15 minutes post-fall. However, there was no documentation that these interventions were reliably implemented. Staff interviews confirmed gaps in documentation and uncertainty about whether new interventions were carried out as planned.
Plan Of Correction
Corrective action will be accomplished for those residents found to have been affected by the deficient ice. Resident #2 no longer resides at the facility. You will identify other residents having the potential to be affected by the same deficient practice. What corrective action will be taken? A resident in the facility will be re-evaluated for bowel and bladder function by August 1st, 2025, by the facility nurse management. Based on the evaluation, the resident will be placed on the proper bowel and bladder program (toileting, check and change routinely, etc.) to ensure that bowel/bladder needs are being met appropriately. The program will then be triggered in point of care for the CNA's to document on every 2 hours or as directed. Facility nurse management will review each bladder evaluation upon admission, quarterly, and during significant changes to ensure that the evaluation is completed appropriately and that the bowel/bladder program is appropriate and meets the needs of the resident. Facility IDT will review each resident with a fall for the past 3 months, ongoing, and complete an analysis as needed. The analysis will include a root cause analysis to determine the underlying factors contributing to the falls. The facility will implement a plan of action based on the root cause analysis, including interventions to prevent future falls. The nurse management will monitor the effectiveness of these interventions over the next 30 days and then weekly for 90 days. Each resident with a fall will be reviewed in the morning clinical meeting daily and in the weekly risk management meeting as part of the facility policy. The facility will also review the documentation related to the fall, including the lack of timely toileting (6 hours before the fall), and ensure that appropriate prevention interventions are in place. An interview was held with Resident #2 regarding multiple falls. Riding toileting to prevent falls should have been implemented, and the resident should have been toileted more frequently before bed, with routine checks and documentation of the 15-minute checks to ensure fall prevention. The root cause analysis was completed, and the facility will implement appropriate corrective actions based on the findings. The DON/RN will oversee the implementation of these actions and ensure ongoing monitoring. The nursing staff will be re-educated on conducting risk assessments and completing timely documentation by August 1st, 2025. They will also be trained on the importance of timely toileting and fall prevention strategies. The Director of Nursing (DON) and Regional Director of Nursing will evaluate the effectiveness of the interventions, conduct audits, and implement continuous quality improvement measures. The results of these evaluations will be reviewed by the facility administrator, and recommendations will be made for ongoing practice improvements. The Nurse V shift will monitor the implementation of the fall prevention program, and the results will be reviewed during the weekly clinical meetings. The facility will ensure that all staff are aware of and adhere to the updated policies and procedures related to fall prevention and resident safety.