Failure to Implement and Revise Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that staff implemented existing accident prevention interventions and did not review or revise interventions after changes in residents' conditions, as evidenced by multiple incidents involving three residents at high risk for falls. One resident with a history of falls, cognitive impairment, and multiple comorbidities experienced several unwitnessed falls, resulting in significant injuries including a right ankle fracture and lacerations. Despite documented care plan interventions such as anti-slip tape, signage, and floor mats, these were not observed in the resident's room during inspection, and staff interviews revealed a lack of awareness or inconsistent application of these interventions. The resident's care plan and fall risk assessments consistently identified high fall risk, but interventions were not reliably maintained or updated following each incident. Another resident, also at high risk for falls due to severe cognitive impairment and muscle weakness, experienced an unwitnessed fall after sliding off the bed. The care plan was updated to include a non-slip cushion as an intervention, but during observation, the cushion was not present, and multiple staff members reported never having seen it in use. This indicates a failure to implement the planned intervention intended to prevent further falls for this resident. A third resident with severe cognitive impairment, a history of falls, and mobility deficits experienced multiple falls, some resulting in head injuries and lacerations. Documentation showed that after several of these falls, no root cause analysis was completed, and no new interventions were implemented or documented in the care plan. Staff interviews further revealed a lack of knowledge regarding fall interventions in place for this resident, and the only intervention consistently identified was a chair alarm. These failures demonstrate a lack of consistent implementation and review of fall prevention strategies for residents at high risk.