Failure to Implement Fall Prevention Intervention for Resident with Repeated Falls
Penalty
Summary
The facility failed to implement a fall prevention intervention for a resident with a significant history of falls. According to the facility's Fall Prevention Program, when a resident experiences a fall, the care plan should be reviewed and a new intervention added before the end of the shift. After a fall on 10/24/2024, the intervention identified was to move the resident closer to the nurse's station and offer snacks between meals, as the fall was attributed to dizziness and hunger. However, the resident was not moved closer to the nurse's station, and there was no documentation that the resident or their family refused a room change. Observations confirmed that the resident continued to reside in a room farthest from the nurse's station, approximately 129 feet away, despite the care plan intervention. The resident involved had multiple medical diagnoses, including Paranoid Schizophrenia, Morbid Obesity, ADHD, Anxiety, and Depression, and was moderately cognitively impaired with a BIMS score of 9. The resident required substantial to maximal assistance with several activities of daily living and had a documented history of numerous falls over several months. Interviews with facility staff, including the Social Worker, MDS Coordinator, and Administrator, confirmed that the intervention to move the resident closer to the nurse's station was not implemented, and there was no clear reason documented for this inaction. The failure to carry out the planned intervention constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision was provided to prevent accidents.