Failure to Individualize and Implement Fall Prevention Interventions and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that fall prevention interventions were individualized and implemented for a resident with significant medical needs, and did not complete required fall follow-up assessments and care plan updates after a fall incident. The resident, who had a history of stroke, aphasia, dysphagia, pressure ulcer, and right-sided weakness, was identified as high risk for falls and required extensive assistance from two or more staff for bed mobility and transfers. Despite these needs, the resident fell out of bed while being cared for by a newly hired CNA working alone during a check and change. The care plan at the time lacked resident-specific interventions and was not updated following the fall. Additionally, the clinical record did not contain documentation of 72-hour post-fall assessments with vital signs, a Post Fall Review assessment, or updates to the care plan as required by facility policy. Interviews with the DON and LPN confirmed that the fall occurred during care provided by a single aide, and that the care plan had not been appropriately individualized or revised after the incident. The facility's policy required documentation and investigation after falls, as well as the implementation of new care plan interventions, but these steps were not completed for this resident.