Failure to Implement and Maintain Effective Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure an environment free from accident hazards and did not fully implement or update fall prevention interventions for a resident with a history of multiple falls. The resident had diagnoses of vascular dementia and hemiparesis/hemiplegia, with documented moderate to severe cognitive impairment, impaired mobility, and a history of falls. The care plan included several interventions such as keeping the environment clutter-free, ensuring appropriate footwear, using Dycem pads and brake extenders on the wheelchair, and encouraging the use of call lights for assistance. Despite these interventions, the resident experienced repeated falls, some resulting in injury, and the interventions were not consistently implemented or adjusted in response to the resident's changing condition and repeated incidents. Multiple fall notes documented that the resident was often found on the floor without appropriate footwear or non-skid socks, and sometimes without the use of the call light. The resident's wheelchair was at times not equipped with the required Dycem pad or brake extenders, and staff interviews revealed uncertainty about whether these interventions were in place or needed. Maintenance staff could not confirm that brake extenders had been installed, and there was no documentation of some interventions being completed. Additionally, the resident's cognitive impairment was well known among staff, who acknowledged that the resident would not reliably remember to use the call light or follow safety instructions, yet interventions were not modified to address this. The facility also failed to follow through on a physician's order for a physical therapy evaluation after a fall, with no evidence that the evaluation was completed or that a refusal was documented. Staff interviews and record reviews confirmed gaps in documentation and implementation of prescribed interventions. The facility's own policies required the maintenance and supervision of assistive devices and documentation of their use in the care plan, but these were not consistently followed for this resident.