Failure to Investigate and Prevent Repeated Resident Falls Resulting in Injury
Penalty
Summary
The facility failed to thoroughly investigate the root cause of repeated falls experienced by a resident and did not implement appropriate fall prevention interventions. The resident, who had a history of falls, severe cognitive impairment, and required extensive assistance with activities of daily living, experienced falls on three separate occasions. After each fall, the facility's investigations were incomplete, lacking critical information such as whether the resident was incontinent, attempting to use the bathroom, the timing of last toileting, use of call light, type of footwear, and whether previously implemented interventions were in place at the time of the falls. Despite the resident being identified as high risk for falls and having a care plan that included interventions such as maintaining a clear pathway, monitoring for side effects of psychotropic medications, encouraging the use of briefs, and use of a tilt-in-space wheelchair, the facility did not update or individualize interventions based on the circumstances of each fall. For example, after the first fall, the only intervention added was to ensure the resident wore briefs at all times, which was later confirmed by staff as not being an appropriate intervention for a resident who was falling while attempting to transfer to the bathroom. Additionally, after subsequent falls, interventions such as non-slip strips were implemented, but these were not consistently updated in the care plan or verified as being in place at the time of later incidents. Actual harm occurred when the resident fell while attempting to transfer herself to the bathroom unsupervised, resulting in a distal left tibia fracture that required hospitalization. The facility's failure to conduct thorough root cause analyses and to implement and document effective, individualized fall prevention interventions contributed to the recurrence of falls and the resulting injury.