Failure to Implement Post-Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement interventions to prevent multiple falls for a resident identified as being at high risk for falls. The resident had severe intellectual disabilities, major depressive disorder, restlessness, agitation, and severely impaired cognitive skills, and was dependent on staff for hygiene and mobility. The care plan identified the resident as at risk for falls and included specific interventions such as placing the bed against the wall, keeping the bed in the lowest position, ensuring proper posture, using floor mats, and applying a perimeter mattress. Despite these measures, the resident experienced multiple unwitnessed falls, each time being found on the floor next to the bed, sometimes with minor injuries. After each fall, incident reports were completed, but no new interventions were documented or implemented to address the repeated falls. Record reviews and staff interviews confirmed that after each fall, there was no evidence of updated interventions or care plan modifications. The Minimum Data Set Coordinator, Nursing Home Administrator, and Director of Nursing—all of whom were not employed at the time of the incidents—were unable to find documentation of any interventions added after the falls. The staff involved in the incidents were no longer employed and did not respond to inquiries. The lack of follow-up interventions after each fall event constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent further accidents.