Failure to Implement and Document Comprehensive Fall Prevention and Post-Fall Assessment
Penalty
Summary
The facility failed to provide a comprehensive, resident-centered fall prevention plan and did not adequately assess residents after a fall, affecting two of three residents reviewed. For one resident with multiple diagnoses including epilepsy, schizophrenia, repeated falls, and agitation, the physician ordered a low bed with a mat beside the bed. However, observations revealed a mattress, not a mat, was placed on the floor, and the Director of Nursing confirmed this discrepancy between the physician's order and what was implemented. Another resident, admitted with a history of falls and multiple medical conditions such as a pubic fracture, diabetes, and seizures, was identified as high risk for falls. The care plan included interventions like a low bed, mat, and grab bars, but these were not implemented until after the resident experienced a fall from bed, resulting in a hematoma above the left eye. Documentation of the fall and injury was inconsistent and incomplete, with delayed and conflicting entries regarding the size and description of the hematoma. The initial fall documentation was not part of the official medical record, and there was no clear record of whether fall prevention interventions were in place at the time of the incident. Interviews with the DON and the resident's family revealed further gaps in communication and documentation. The family had informed staff of the resident's fall risk upon admission and requested bed rails, but staff indicated a physician order was required. The DON confirmed that documentation did not verify if the bed was in a low position or if nonskid socks were used as intended. The facility's fall policy required follow-up on any fall with injury, but there was no evidence that this was consistently followed, as documentation of injury assessment and intervention implementation was lacking.