Failure to Implement Effective Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was as free from accident hazards as possible by not implementing an appropriate intervention following a fall. The resident, who had vascular dementia, a history of repeated falls, and severe cognitive impairment (BIMS score of 7), required substantial to maximal assistance with mobility and transfers. The resident was found on the floor after an unwitnessed fall, having rolled out of bed while attempting to go to the bathroom. The care plan identified the resident as being at risk for falls, and the incident report documented the fall event. Following the fall, the only intervention added to the care plan was for CNA staff to offer toileting assistance during rounding. However, this intervention was not appropriate, as CNA staff had already been in-serviced to round on residents every two hours and as needed. The failure to implement a new or effective intervention after the fall resulted in the resident not being as free from accident hazards as possible.