Failure to Implement Care Planned Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement care planned fall prevention interventions for two residents who were identified as high risk for falls. For one resident with diagnoses including dementia, rheumatoid arthritis, prostate cancer, vision problems, and high blood pressure, the care plan required staff to follow the resident to his room and assist with toileting or lying down. Despite this intervention, the resident experienced multiple falls in his room, including an incident where he attempted to transfer himself from his wheelchair to his bed, resulting in a fractured right hip that required surgical repair. The Director of Nursing confirmed that staff did not follow the care plan intervention at the time of the fall. Another resident, also at high risk for falls due to conditions such as dementia, depression, anxiety, insomnia, repeated falls, chronic pain, heart failure, lung disease, incontinence, arthritis, osteoporosis, and prior fractures, had a care plan intervention to ensure the use of non-skid footwear when ambulating or mobilizing in a wheelchair. This intervention was not followed, and the resident was found wearing slippers that were not non-skid at the time of a fall. The resident attempted to self-transfer from a wheelchair to a recliner, slipped, and sustained a fractured left hip requiring surgical repair. A post-fall committee meeting identified inappropriate footwear as the root cause of the fall, and a nurse confirmed the care plan was not followed. Both residents had documented histories of falls and were assessed as high risk using the Morse Fall Scale. The facility's own policy required the implementation of evidence-based interventions for residents at risk for falls, including addressing fall risks in care plans and providing non-skid footwear. The failure to follow these care planned interventions directly resulted in avoidable falls and serious injuries for both residents.