Failure to Assess and Implement Comprehensive Fall Prevention Measures
Penalty
Summary
The facility failed to comprehensively assess and address fall risks for two residents with a history of falls and significant medical vulnerabilities. One resident, who had a history of traumatic brain injuries and severe cognitive impairment, was admitted with multiple facial fractures and a traumatic brain injury. Despite being identified as high risk for falls on admission, there was no fall prevention care plan developed for this resident until after multiple unwitnessed falls occurred, including one that resulted in a subdural hematoma and hospitalization. The care plan did not include specific interventions or clearly defined supervision levels, and staff were unclear about the frequency and documentation of required checks. For this resident, incident reports and progress notes documented repeated falls, wandering, and self-transferring behaviors, but failed to include comprehensive fall analyses or root cause assessments. Interventions such as gripper socks, soft touch call lights, and frequent checks were inconsistently implemented and not reflected in the care plan. Staff interviews revealed confusion about the meaning and frequency of 'frequent checks,' and documentation of interventions was lacking. The care plan was not updated in a timely manner, and interventions were not individualized based on comprehensive assessments of the resident's needs, including toileting and supervision requirements. A second resident, also identified as high risk for falls due to multiple fractures, cognitive impairment, and inability to follow directions, experienced several falls. Incident reports and post-fall analyses were incomplete, lacking documentation of mental status, predisposing factors, and root cause conclusions. Interventions such as frequent checks, fall mats, and medication reviews were inconsistently documented and not incorporated into the care plan. The care plan did not reflect new interventions or comprehensive assessments to address the resident's individualized needs, including toileting and supervision. Staff and the DON confirmed that comprehensive analyses and root cause assessments were not consistently completed for each fall, resulting in inadequate fall prevention measures.