Failure to Prevent Recurrent Falls in Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls, due to poor safety awareness, severe cognitive impairment, and a history of repeated falls, was provided with adequate care and services to prevent recurrent falls. Despite the resident's documented diagnoses of dementia, Alzheimer's disease, and previous fractures, the facility did not conduct timely fall assessments and reassessments after each unwitnessed fall, as required by their Fall Management Program. The care plans were not revised to address the specific causes of each fall, such as the resident's behavior, poor safety awareness, and inability to communicate, nor did they include individualized interventions based on the resident's needs and behaviors. The facility's records showed that after multiple unwitnessed falls, interventions such as bed and wheelchair alarms were implemented; however, there was no evidence that the resident understood the purpose of these alarms due to her cognitive impairment. Staff interviews confirmed that the alarms were not new interventions and that the resident was not placed under close monitoring or moved closer to the nurse's station, despite being identified as a high fall risk. The care plans primarily focused on monitoring the effects of medications rather than addressing the resident's behavioral risks and need for increased supervision. As a result of these deficiencies, the resident experienced another unwitnessed fall, which led to significant injuries including a left hip fracture and head bruising, requiring transfer to an acute care hospital and subsequent surgery. The facility's own policies on fall management, resident safety, and dementia care were not followed, as there was a lack of person-centered observation, failure to update care plans with effective interventions, and insufficient communication among staff regarding the resident's fall risk and required monitoring.