Failure to Complete Root Cause Analysis and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to complete thorough root cause analyses and did not consistently implement care planned interventions to prevent further falls for two residents with a history of falls and cognitive impairment. For one resident with dementia, muscle weakness, and a history of falls, the care plan required the use of bed and chair alarms and frequent supervision. Despite these interventions being documented, observations revealed that the bed alarm was not in place while the resident was in bed, and staff interviews confirmed that alarms were not always moved as required. Documentation showed that the resident's fall risk status increased over time, but interventions were not reliably implemented as directed in the care plan. Another resident with multiple diagnoses, including neuromuscular bladder dysfunction, dementia, and repeated falls, experienced several falls after admission. The care plan included interventions such as the use of a leg bag for catheter management, reminders to use the call light, and staff assistance with toileting. However, after multiple falls, the facility did not consistently conduct thorough investigations or implement new interventions based on the root causes identified. The resident reported getting tangled in catheter tubing and forgetting to use the call light, but these factors were not always addressed with new or modified interventions. Staff documentation indicated that the leg bag intervention was not used as required, and this was not consistently documented as refused by the resident. Facility policy required that interventions be based on specific risks and causes identified through evaluation and that staff monitor the placement of position alarms per an established schedule. Despite these policies, the facility did not ensure that interventions were in place or that new interventions were implemented following falls. The lack of thorough root cause analysis and failure to follow or update care plans placed the residents at risk for further falls and associated injuries.