Failure to Evaluate and Document Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident at risk for falls received adequate supervision and that accident hazards were minimized. The resident, who had severe cognitive impairment, was non-ambulatory, and required assistance for toileting and bed mobility, was found on the floor next to their bed with bleeding from the nostrils and a hematoma to the forehead. The incident took place during morning rounds, and the resident was subsequently transferred to the hospital, where a nasal bone fracture was diagnosed. The resident had a documented history of multiple falls, and their care plan included interventions such as frequent monitoring, keeping the bed in the lowest position, and ensuring the call bell was within reach. Despite these interventions, the facility did not provide documented evidence that the effectiveness of the implemented interventions was evaluated after each fall. The care plan and fall risk assessments were updated following each incident, but the interventions remained largely unchanged, and there was no documentation of ongoing monitoring frequency beyond the initial 48-hour post-fall period. Staff interviews confirmed that monitoring was performed every 30 minutes for 48 hours after a fall, but after this period, the frequency of monitoring was not clearly documented, and there was no evidence of reassessment or adjustment of interventions based on the resident's ongoing risk. The facility's fall risk assessment tool did not identify the level of fall risk, only the risk factors, and there was no documentation that the resident's fall risk was reassessed or that interventions were modified in response to repeated incidents. Staff reported that the resident was kept in a high-visibility area when out of bed and that frequent rounds were made, but these actions were not consistently documented. The lack of evaluation of intervention effectiveness and insufficient documentation of monitoring frequency contributed to the deficiency in providing adequate supervision to prevent accidents.