Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to implement individualized interventions and adequate supervision to prevent avoidable falls for a resident with multiple risk factors. The resident had a history of cerebral infarction, muscle wasting and atrophy, difficulty walking, lack of coordination, aphasia, and impaired vision. The resident was always incontinent of bladder and bowel, required assistance of two staff for transfers and ambulation, and was identified as being at risk for falls due to impaired cognition, medication use, poor safety awareness, cardiac disease, and decreased mobility. The care plan included interventions such as anticipating needs, ensuring the call light was within reach, and using fall pads, but these interventions were not consistently or effectively implemented. The resident experienced multiple falls over a short period. Each fall investigation revealed that the resident was attempting to ambulate to the bathroom independently, despite being care planned for assistance. Documentation showed inconsistent and infrequent toileting, with significant gaps between toileting times, sometimes up to 11 hours. The fall investigations did not address the lack of timely toileting or incontinent care prior to the falls. Additionally, there were inconsistencies in the bowel and bladder assessment, with conflicting information about the resident's continence status. After each fall, the care plan was updated with new interventions, such as posting signs, ensuring nonskid footwear, and implementing 15-minute checks post-fall. However, there was no documentation that these interventions, particularly the 15-minute checks, were actually implemented. The Director of Nursing was unable to provide evidence that the required checks were performed. The lack of consistent implementation and documentation of individualized interventions contributed to the resident's repeated falls.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #2 no longer resides at a facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Each 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/bladder program (toileting, check and change routinely, etc.) to ensure that bowel and bladder needs are being met appropriately. The program will then be triggered in the point of care for the CNA to document on every 2 hours or as directed. The facility nurse management will review each bowel/bladder evaluation upon admission, quarterly, and with significant change to ensure that the evaluation is completed appropriately and that the bowel/bladder program is appropriate and meets the needs of the resident. The facility IDT will review each resident with a fall for the past 30 days by August 1st, 2025, and each fall going forward to ensure that root cause analysis was completed and that toileting needs are being met where needed. Interventions will be implemented according to findings upon review. The facility management will also review each fall for the past 30 days by August 1st, 2025, and each fall going forward to ensure that safety checks were complete as care planned and forms are present with the root cause analysis audit. What measures will be put into place or what systematic changes will be made to ensure that the deficient practice does not recur? The nurse management team will be re-educated by the Regional Director on completing bowel/bladder evaluations, conducting root cause analysis for falls, and implementing appropriate interventions based on the root cause analysis (toileting, 15-minute checks, etc.) along with the fall prevention policy and procedure on July 24th, 2025. The nursing staff (nurses and CNAs) will be re-educated by the Staff Educator/Designee by August 1st, 2025, on completing bowel/bladder evaluations, conducting root cause analysis for falls, implementing and completing appropriate interventions (toileting, 15-minute checks), and the fall prevention policy and procedure. This re-education will include documentation of the toileting program in the point of care for the CNAs. The DON/Risk Manager will complete an audit of each resident who has a fall to ensure that the root cause analysis was completed, interventions were placed according to the root cause analysis, safety check sheets are completed as ordered, and any testing needs are being met as care planned based on bowel and bladder programs. The Nurse Management team will complete an audit each shift to monitor the documentation and the toileting programs for individual residents. How will the corrective action be monitored to ensure the deficient practice will not recur? The results of the audits will be forwarded to the Administrator and the Director of Nursing for review. The audit will then be forwarded to the monthly Quality Assurance Meeting for further review and recommendations. The audits will continue daily for 30 days and then weekly for 90 days. Each resident with a fall will be reviewed at the morning clinical meeting daily and continue to be reviewed in the weekly at-risk meeting indefinitely as part of the facility policy and procedure. Date of Compliance: August 1st, 2025