Failure to Timely Implement Fall Interventions for At-Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to timely develop and implement fall interventions for a resident who was at risk for falls. The resident, who had multiple diagnoses including encephalopathy, altered mental status, diabetes, depression, acute respiratory failure, chronic kidney disease, anemia, peripheral vascular disease, visual hallucinations, congestive heart failure, chronic atrial fibrillation, and obstructive sleep apnea, was admitted and assessed as being at risk for falls. The admission assessment indicated the need to follow the facility's fall protocol and to anticipate the resident's needs. However, no specific fall interventions were care planned until several days after admission. An incident occurred in which the resident was found on the floor with a skin tear, requiring treatment and assistance back to bed. Review of the care plan showed that fall interventions were not added until after this incident. Staff interviews confirmed that fall interventions were not care planned until after the fall, and facility policy required that fall interventions be initiated on the resident's baseline care plan. This lapse affected the resident's safety and represented a failure to provide adequate supervision and accident hazard prevention as required.