Failure to Follow Fall Prevention Policy and Update Care Plans After Falls
Penalty
Summary
The facility failed to follow its Fall Prevention and Management policy for three residents identified as high risk for falls. For one resident with severe cognitive impairment and multiple comorbidities, the care plan was not updated after a fall, and no new interventions were documented to reduce future fall risk. The fall was not recorded in the electronic medical record, and there was no documentation of post-fall monitoring or follow-up, despite the resident being sent to the emergency department for evaluation. The Director of Nursing confirmed that required documentation and monitoring were not completed as per facility policy. Another resident with moderate cognitive impairment and a history of repeated falls experienced multiple falls, but incident reports lacked root cause analyses and did not document new interventions to prevent further incidents. Required sections of the incident reports, such as environmental and physiological factors, were left blank. Observations revealed that prescribed fall prevention interventions, such as side rails and floor mats, were not in place at the time of surveyor inspection, and the care plan was not updated after each fall as required. A third resident, also severely cognitively impaired and dependent for all activities of daily living, experienced several falls. Incident reports for these events did not include root cause analyses or documentation of new interventions. The care plan was not updated following these incidents, and the activity director was unaware of the resident's fall interventions and had not completed an activity assessment since admission. The facility's policy requires a root cause analysis and care plan update with new interventions after each fall, but these steps were not followed for the residents reviewed.