Failure to Investigate Falls and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a complete investigation and root cause analysis was conducted after a resident sustained a fall, and did not implement fall safety interventions as outlined in residents' care plans. For one resident with severe cognitive impairment and a history of behaviors such as rejection of care, there was no evidence of a completed post-fall investigation or review after the resident reported a fall that resulted in an inability to move his right leg and required hospital transfer. Additionally, the resident's annual fall risk assessment was found to be incomplete. Another resident with multiple complex diagnoses, including chronic respiratory failure and hemiplegia, was observed without required protective headgear while in bed, despite hospital discharge instructions indicating helmet use during transfers and when out of bed. There was no documentation in the care plan or physician orders specifying the need, frequency, or rationale for the head protection, and staff confirmed that this information was only added after surveyors requested clarification. Prior to this, there was no system in place to ensure consistent staff guidance regarding the use of head protection for this resident. A third resident, who was alert and oriented with diagnoses including diabetes and paraplegia, had care plan interventions for a low bed and fall mat, but was observed in bed with the bed in a high position and the fall mat folded against the wall. Staff confirmed that the prescribed fall prevention interventions were not in place at the time of observation. These findings demonstrate a failure to follow established care plans and policies for fall prevention and accident hazard mitigation for multiple residents.