Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place and properly documented for two residents with a history of falls. One resident, with diagnoses including cerebral palsy and epilepsy, was identified as being at risk for falls and had specific interventions ordered, such as a perimeter mattress and bilateral enabler bars, to be checked every shift. Despite these orders, after a bed change, the perimeter mattress and enabler bars were not in place, and staff continued to document in the Treatment Administration Record that these interventions were present when they were not. The resident experienced a fall while self-transferring and later reported another incident of sliding from the bed to the floor, noting the absence of the usual side rail for support. The Director of Nursing confirmed that the interventions were not included in the fall care plan and had not been in place since the bed change. Another resident, admitted with acute respiratory failure, seizure disorder, and chronic heart failure, was also assessed as being at risk for falls and required assistance with all activities of daily living. This resident experienced an unwitnessed fall, which was reported by the family directly to the physician. The post-fall assessment was documented as normal, but the event was not communicated to nursing staff, and the intervention to increase rounding frequency was not implemented because staff were unaware of the fall. The fall event form was completed six days after the incident, and no comprehensive evaluation was documented. The Director of Nursing and Nurse Practitioner confirmed that the fall was not discussed during daily rounds and that nursing staff had not reviewed the physician's progress notes where the fall was documented. Facility policy required that all resident-related incidents be documented in the medical record, with all facts collected and incident reports submitted to the Director of Nursing and administration within 24 hours. In both cases, the facility failed to follow its own policy for documentation, communication, and implementation of fall prevention interventions, resulting in a lack of adequate supervision and failure to maintain a hazard-free environment for residents at risk for falls.