Failure to Implement and Update Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to accurately assess and implement appropriate interventions to prevent accidents for two residents identified as being at high risk for falls. For one resident with a history of Parkinson’s disease, dementia, and a recent femur fracture, staff inconsistently assessed the resident’s ability to unlock wheelchair brakes and did not include specific interventions in the care plan regarding the placement of the resident at a table with both wheelchair brakes locked. Observations showed the resident was often left alone in a wheelchair with brakes locked, and staff provided conflicting information about the resident’s ability to unlock the brakes. The care plan did not address the use of locked brakes or proximity to the table as interventions, and the DON acknowledged that locking both brakes and pushing the resident up to the table would constitute a restraint, which was not care planned. Another resident, admitted after a fall resulting in a brain injury, experienced multiple falls within the facility. The resident had severe cognitive impairment, was dependent on staff for mobility and transfers, and had a documented history of vertigo and unsteadiness. Despite repeated falls, initial care plan interventions were limited to call light use and non-skid footwear, and only after subsequent falls were additional interventions such as therapy screens, anti-rollback devices, and increased monitoring implemented. Staff interviews revealed inconsistent awareness of the resident’s fall history and interventions, and the care plan was not promptly updated to reflect the resident’s high fall risk and need for individualized precautions. The facility’s fall prevention policy requires comprehensive assessment, individualized care planning, and prompt intervention following falls, including root cause analysis and care plan updates. However, in both cases, there were delays and omissions in care planning and intervention implementation, as well as inconsistent communication among staff regarding residents’ fall risks and required precautions. These failures resulted in the facility not ensuring a safe environment free from accident hazards and not providing adequate supervision and interventions to prevent accidents for residents at high risk for falls.