Failure to Implement and Document Fall Prevention and Post-Fall Interventions
Penalty
Summary
Staff failed to implement and document necessary fall prevention and post-fall interventions for two residents with significant cognitive and physical impairments. One resident, with diagnoses including dementia, major depressive disorder with psychotic symptoms, reduced mobility, and delusional disorders, required substantial assistance with transfers and had a history of falls. Despite the resident's guardian requesting the bed be kept in a low position and a fall mat be used, neither intervention was in place. The resident's care plan did not include these interventions, and after an unwitnessed fall, there was no evidence that neurochecks were performed. The Director of Nursing confirmed these interventions were not implemented as required. Another resident, also with severe cognitive impairment and a history of falls, had multiple falls documented without adequate information regarding the cause or circumstances of the incidents. The care plan identified the resident as being at risk for falls and directed staff to monitor for changes that could increase fall risk. However, documentation was insufficient to determine the cause of the falls, and neurochecks were not completed following the incidents. The Director of Nursing acknowledged the lack of documentation and post-fall assessments.