Failure to Implement Immediate Fall Prevention Interventions
Penalty
Summary
The facility failed to implement immediate interventions to prevent future falls for two residents who were reviewed for falls. For one resident with a history of dementia, muscle weakness, and impaired mobility, the care plan identified a high risk for falls and included interventions such as bed alarms, hourly rounding, and proper footwear. Despite these measures, the resident experienced a fall resulting in a left wrist fracture. After returning from the hospital, no new immediate interventions were implemented to prevent further falls. Subsequently, the resident suffered another fall, resulting in a right hip fracture. Interviews with staff confirmed that immediate interventions were not put in place after the initial fall, and care plan updates were delayed until after interdisciplinary team meetings. Another resident with Parkinson's disease, dementia, and muscle weakness was also identified as being at risk for falls. This resident experienced multiple falls over several months, often while attempting to transfer or ambulate without assistance. The care plan included interventions such as education on call light use, anti-skid strips, and keeping personal items within reach. However, after each fall, the immediate interventions implemented were limited to re-education or encouragement to use the call light, which staff and the DON acknowledged would not prevent further falls. Documentation of immediate interventions and care plan updates was inconsistent or lacking, and staff interviews revealed confusion about responsibilities for updating care plans and implementing new interventions. The facility's policies required immediate implementation of interventions following a fall and prompt updates to care plans. However, the records and staff interviews demonstrated that these procedures were not consistently followed. Immediate interventions were either not implemented or were insufficient to prevent further falls, and care plan updates were often delayed or incomplete. This deficient practice resulted in repeated falls and injuries for the residents involved.