Failure to Identify Root Causes and Individualize Fall Prevention Strategies
Penalty
Summary
The facility failed to utilize a system for identifying root causes for falls and did not develop or implement individualized fall prevention strategies for a resident with a history of multiple unwitnessed falls. Observations showed the resident ambulating with a walker and requiring verbal cues to locate her room. Nursing progress notes documented several unwitnessed falls, but did not include any analysis of contributing factors or possible causes for these incidents. Review of the resident's electronic health record also failed to show documentation of root cause identification for the falls. Interviews revealed that staff felt they needed further training in root cause analysis and struggled to understand the process. The resident's care plans, while noting fall risk and listing general interventions such as assistance with ambulation, call light availability, and therapy referrals, did not include interventions tailored to the specific causes of the resident's falls. The facility's fall prevention policy outlined general risk protocols but did not ensure that individualized interventions were developed based on root cause analysis for residents who experienced falls.