Failure to Prevent Repeated Falls Due to Inadequate Evaluation and Communication of Fall Interventions
Penalty
Summary
The facility failed to ensure that two of three sampled residents were free from accident hazards and received adequate supervision to prevent accidents. Post-fall evaluations did not determine the reasons for repeated falls, and the care plan interventions for these residents were not reevaluated for effectiveness. New interventions were not consistently developed to prevent further falls and injuries, and direct care staff were not adequately informed on how to identify high-risk fall residents or locate their fall plans of care. One resident, with diagnoses including dementia, difficulty walking, anxiety disorder, and a history of repeated falls, experienced multiple falls during their stay. Despite being identified as a high fall risk, the resident's care plan interventions, such as one-to-one supervision and toileting programs, were inconsistently applied and not evaluated for effectiveness. Several falls occurred during shifts not covered by the interventions, and repeated interventions were implemented without assessing their impact. Documentation showed that the interdisciplinary team did not address falls occurring during the day shift, and there was no clear rationale for changes in supervision levels. Another resident, also with dementia and a history of falls, was assessed as a moderate fall risk and had significant cognitive impairment. The care plan included interventions such as frequent checks and reminders to use the call light, despite the resident's inability to use the call light due to cognitive limitations. Staff interviews revealed a lack of awareness of the resident's fall risk status and care plan details, and the electronic care plan system used by CNAs did not provide comprehensive information. The Director of Nursing confirmed gaps in root cause analysis, care planning, and communication of fall risk interventions to direct care staff.