Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to identify and implement effective fall prevention interventions for multiple residents, resulting in repeated falls and injuries. For one resident with a history of falls and significant mobility impairments, the care plan directed staff to keep the walker within reach and encourage its use. However, on multiple occasions, the walker and wheelchair were found out of reach, and the resident attempted to ambulate independently, leading to falls. Fall investigations did not consistently result in new or effective interventions, and previously identified interventions were not reliably implemented. Another resident with severe cognitive impairment and a history of falls experienced several unwitnessed falls, some resulting in injury. The care plan required supervision and keeping frequently used items within reach, but falls occurred when the resident attempted to use the bathroom without assistance, often without activating the call light or using mobility aids. Fall investigations frequently failed to add new interventions to the care plan, and staff were unclear about who was responsible for updating care plans with fall prevention strategies. A third resident, dependent on staff for transfers and toileting, experienced a near-miss fall and a fall from a mechanical lift. The care plan included general fall risk interventions, but specific incidents, such as sliding out of bed after being awakened or falling from the lift, were not followed by timely updates to the care plan. Staff were not always aware of new interventions following these events, and fall investigations lacked thorough root cause analysis. The facility's own policy required assessment and intervention after each fall, but this was not consistently followed.