Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for two residents with significant cognitive and physical impairments. One resident with diagnoses including multiple sclerosis, epilepsy, and a history of falls had a care plan directing staff to educate and re-educate him on the use of his call light and to ensure needed items were within reach. Despite these interventions, the resident experienced multiple falls, and documentation showed that staff did not implement new interventions following these incidents. Staff interviews confirmed that while care plans and updates were accessible, there was a lack of consistent follow-through on implementing and updating fall prevention measures. Another resident with a history of encephalopathy, dementia, fractures, and multiple falls had a care plan requiring staff to keep her call light within reach and to respond promptly to requests for assistance. Observations revealed that the resident's call light was repeatedly placed out of reach, both hooked to the wall and on the bedside table, making it inaccessible. Staff interviews corroborated that call lights should be within reach, but this was not consistently practiced, directly contradicting the care plan directives. The facility's policy required maintaining an environment free of accident hazards and providing adequate supervision and assistive devices to prevent accidents. However, the failure to ensure that fall interventions, such as accessible call lights and updated care plans, were consistently implemented for these residents resulted in a deficiency. These lapses placed the residents at risk for further falls and injuries, as evidenced by the repeated incidents and lack of effective intervention.