Failure to Implement and Document Fall Prevention and Post-Fall Assessments
Penalty
Summary
The facility failed to provide appropriate interventions to prevent falls and did not complete required neurological assessments after unwitnessed falls for several residents. For one resident with severe cognitive impairment and a history of falls, the care plan was not updated with new interventions after multiple falls occurred on consecutive days. Progress notes documented repeated incidents of the resident being found on the floor, but no additional fall prevention strategies were added to the care plan following these events. Another resident experienced multiple unwitnessed falls, but the neurological assessment flow sheets showed that vital signs, level of consciousness, pupil response, motor functions, and pain response were not consistently documented as assessed after these incidents. This lack of documentation was also observed for another resident with severe cognitive impairment and a history of falls, where neurological checks were incomplete or missing after unwitnessed falls, despite facility policy requiring such assessments for a 72-hour period following an unwitnessed fall. Additionally, a resident with mild cognitive impairment and multiple medical diagnoses, including a history of falls, was observed with fall prevention equipment not consistently in use, such as a fall mat being folded and not placed by the bed. The care plan for this resident included general fall prevention measures, but after documented falls, there was no evidence of individualized interventions being added. Staff interviews revealed inconsistent knowledge and use of care plans and interventions, and the facility was unable to provide a current policy regarding fall interventions after a fall, relying instead on an outdated neurological assessment policy.