Failure to Assess and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that the root cause of falls was properly assessed and that appropriate care plan interventions were developed and implemented to prevent further falls for a resident with significant fall risk. The resident, who had diagnoses including Alzheimer's dementia and a recent hip fracture, was admitted for rehabilitation and was noted to have an unsteady gait, weakness, poor balance, and required assistance for ambulation and transfers. Despite being identified as high risk for falls and in need of staff assistance for toileting and mobility, the care plan did not specify the required level of assistance for activities of daily living (ADLs), weight bearing status, or use of assistive devices. Additionally, there was no scheduled toileting plan in place prior to the resident experiencing two falls within a short period, one of which resulted in a fractured leg. The first fall occurred when the resident attempted to get up from a recliner to use the bathroom and was wearing slick shoes, leading to a loss of balance. The second fall happened when the resident again attempted to walk to and from the bathroom unassisted, resulting in her legs giving out and causing a fracture to her distal femur. Both falls were unwitnessed, and documentation indicated that the resident was not on a scheduled toileting plan, nor had an assessment been completed to determine the need for such a plan. The care plan was only updated to include increased scheduled toileting after the resident was hospitalized for the fracture. Interviews with facility leadership and therapy staff confirmed that the resident always required staff assistance for ambulation due to confusion and weakness, and that the root cause of the falls was related to the need for toileting, incontinence, and the absence of a scheduled toileting plan. The facility's fall policy required assessment, documentation, and revision of care plans following falls, but these steps were not adequately implemented prior to the incidents. The lack of timely and comprehensive assessment and intervention contributed to the resident's repeated falls and injury.