Failure to Analyze Fall Trends and Implement Effective Interventions
Penalty
Summary
The facility failed to assess or analyze trends of falls to determine causal factors or root causes and did not implement effective interventions to prevent or reduce the risk of falls with major injury for a resident with a history of multiple falls. The resident, who had diagnoses of Parkinson's disease, dementia, and depression, experienced seven falls over a period of several months, resulting in significant injuries including spinal compression fractures and a rib fracture. Despite being identified as high risk for falls and having a care plan with various interventions, there was no evidence that these interventions were consistently implemented or that their effectiveness was evaluated. Documentation revealed gaps in the recording of ambulation and toileting schedules, with several months showing no documentation of required ambulation or toileting times. Staff interviews indicated a lack of awareness or understanding of the resident's care plan interventions, such as scheduled ambulation and toileting. Additionally, recommendations from the pharmacist regarding medication review and orthostatic blood pressure monitoring were not acted upon, and there was no indication that root cause analyses were performed after each fall event. The facility's quality assurance and performance improvement (QAPI) records showed ongoing concerns with falls and falls with injury, but there was no evidence of systematic analysis or targeted interventions for the resident in question. The facility's fall policy did not specify the need for immediate intervention following a fall, and event reports often lacked root cause analysis. As a result, the resident continued to experience falls with significant injuries, and the facility did not demonstrate adequate supervision or hazard mitigation to prevent accidents.