Failure to Complete Fall Investigations and Implement Care Plan Interventions
Penalty
Summary
The facility failed to ensure thorough fall investigations were completed, resident care plans were revised to reflect current fall interventions, and fall interventions were in place as ordered for three residents reviewed for falls. For one resident with severe cognitive impairment, hemiplegia, and a history of falls, there were multiple unwitnessed falls. Documentation revealed that required interventions such as low bed position and bilateral floor mats were not consistently included in the care plan or physician orders, and fall risk assessments were inaccurately completed, failing to reflect recent falls. Additionally, the care plan was erroneously marked as resolved, resulting in the omission of necessary fall prevention interventions. Another resident with moderate cognitive impairment and mobility limitations experienced a fall that was not properly documented in the progress notes, and required post-fall assessments, including pain and fall risk assessments, were not completed in a timely manner. Vital signs were not documented at the time of the fall, and there was no evidence that witness statements were obtained or recorded. The incident report did not clarify whether the call light was within reach or activated at the time of the fall, and follow-up documentation was delayed. A third resident, with a history of falls and cognitive deficits, was observed multiple times with only one fall mat in place despite care plan interventions specifying bilateral floor mats. Staff interviews confirmed the absence of the required fall mat on one side of the bed. Facility policy required immediate assessment, investigation, and implementation of interventions after a fall, as well as documentation of the incident and notifications, but these procedures were not consistently followed for the residents involved.