Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent avoidable accidents, specifically repeated falls, for a resident with dementia and atrial fibrillation on anticoagulation. Despite the resident being identified as high risk for falls through multiple Morse Fall Scale evaluations and having a documented history of nine falls over several months, the facility did not consistently develop or update individualized fall prevention interventions after each incident. The care plans reviewed did not reflect new or revised interventions following several of the resident's falls, and only one new intervention was implemented after two falls on the same day. The facility's own policies require that staff identify and implement resident-specific interventions based on ongoing assessments and that care plans be updated when outcomes are not met or when a resident experiences significant changes, such as repeated falls. However, documentation and interviews revealed that the process for updating care plans and implementing new interventions was not consistently followed. Nurses did not routinely update care plans immediately after a fall, and the Director of Nursing confirmed that a new intervention should have been implemented after every fall, which did not occur in this case. Interviews with staff indicated a lack of clarity and consistency in communication and implementation of fall prevention strategies. Certified Nursing Assistants relied on nurses to inform them of new interventions, but nurses did not always update care plans or communicate changes promptly. The resident continued to experience falls, some resulting in injury and hospital transfers, without evidence of a systematic approach to reassessing and modifying interventions as required by facility policy.