Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and monitor fall prevention interventions as outlined in the care plan for a resident identified as high risk for falls. Despite documented falls and a care plan that included specific interventions such as the use of an anti-roll back device on the wheelchair and a routine toileting schedule, staff interviews revealed that these interventions were not consistently communicated or followed. Nurse aides were unaware of the routine toileting plan, and the resident continued to toilet independently without the scheduled assistance intended to reduce fall risk. The care plan had been updated to address the resident's needs after each fall, but the interventions were not effectively put into practice or monitored by staff. The resident had a history of weakness, difficulty walking, and was assessed as high risk for falls on multiple occasions. Event documentation showed the resident experienced falls while attempting to use the bathroom independently, including one incident where an unlocked wheelchair brake contributed to the fall. Although the care plan was revised to address these risks, including scheduled toileting and equipment adjustments, staff interviews and the DON's confirmation indicated a lack of awareness and implementation of these interventions, resulting in continued risk for the resident.