Failure to Implement Fall Prevention Interventions After Initial Fall
Penalty
Summary
The facility failed to implement additional fall prevention interventions after a resident experienced a fall. Following an unwitnessed fall in the resident's room, the resident was found on the floor next to his bed, having attempted to get up and slid to the floor. The care plan identified the resident as high risk for falls with a history of previous falls, and the only intervention initiated after the incident was a urinalysis to rule out infection due to observed confusion. No other interventions were documented or put in place to address the resident's fall risk after the initial event. Subsequently, the resident experienced another unwitnessed fall while attempting to self-transfer to the restroom, resulting in four fractured ribs and requiring transfer to the emergency department for further evaluation and treatment. The resident's medical history included chronic obstructive pulmonary disease, chronic kidney disease, difficulty walking, unsteadiness on feet, depression, history of falling, and metabolic encephalopathy. Staff interviews confirmed that no additional fall prevention measures were implemented between the two falls, despite the resident's high risk status and recent change in mental status.