Failure to Accurately Assess Fall Risk and Implement Post-Fall Interventions
Penalty
Summary
A deficiency occurred when the facility failed to perform an accurate fall risk assessment, develop and implement appropriate post-fall interventions, and provide adequate monitoring and documentation for a resident with a known history of falls. The resident, who was cognitively impaired and had multiple medical diagnoses including a previous fall, was found on the floor after attempting to get out of bed. Despite being on anticoagulation therapy (Eliquis) and having a high fall risk score on previous assessments, the resident's most recent fall risk assessment inaccurately reflected a low risk. This led to a lack of appropriate care planning and interventions to prevent further falls. Following the fall, there was no evidence of the required 72-hour post-fall monitoring or documentation, and the resident was not sent to the hospital until several days later when he exhibited neck pain and was found to have multiple acute cervical fractures. Interviews with staff, including the LPN, DON, MDS Coordinator, and Medical Director, confirmed that the fall risk assessment was not accurately completed, the care plan was not updated with effective interventions, and post-fall monitoring was not performed as required by facility policy.