Failure to Implement Fall Management and Notification Procedures
Penalty
Summary
The facility failed to implement appropriate fall management interventions for a resident with a high risk for falls, as evidenced by multiple lapses in monitoring, care planning, interdisciplinary team (IDT) involvement, and notification of the responsible party. The resident, who had diagnoses including unspecified fall, muscle weakness, gait abnormalities, and cellulitis, experienced five unwitnessed falls during their stay. After each fall, licensed nurses did not document monitoring of the resident every shift for 72 hours as required, and there was no evidence that the IDT met to discuss three of the falls. Additionally, after the resident's first fall, no care plan was developed to address the incident and prevent further falls. Further review revealed that the resident's responsible party, identified as the resident's son, was not notified after two of the falls, despite facility policy requiring such notification. Documentation incorrectly indicated the resident was self-responsible, leading to a failure in communication with the designated responsible party. These deficiencies were confirmed by the Director of Nursing during interviews and record reviews, and were not in accordance with the facility's policies on change in condition and care planning.