Failure to Implement Appropriate Fall Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement appropriate fall prevention interventions for a resident with a history of multiple falls and cognitive impairment. The resident, who had diagnoses including cerebrovascular accident (CVA), osteoarthritis, depression, diabetes, hemiplegia, and short-term memory deficits, experienced several falls over a period of months. Despite documented falls in both common areas and the resident's bathroom, the interventions implemented by the facility primarily consisted of education and signage, such as reminders to lock wheelchair brakes and to wear non-skid socks or shoes. These interventions were not tailored to the resident's cognitive limitations, as the resident had moderate cognitive loss and required substantial to maximal assistance with transfers. Staff interviews confirmed that the interventions were not appropriate for the resident's cognitive status. The restorative nurse and the director of nursing both acknowledged that education and signage were insufficient for a resident with cognitive impairment. The facility's own policies required ongoing assessment and the implementation of pertinent interventions to prevent subsequent falls, but the actions taken did not address the resident's specific needs, resulting in repeated falls and a failure to ensure a safe environment free from accident hazards.