Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement appropriate interventions to prevent accident hazards for two residents with a history of falls. For one resident with a history of stroke, difficulty walking, and muscle weakness, the care plan required non-skid footwear at all times. However, after an unwitnessed fall that resulted in a femoral neck fracture and subsequent hospitalization, the resident was observed on two occasions without non-skid footwear, instead wearing regular socks. The DON confirmed that non-skid footwear should have been in place as per the care plan. Another resident with dementia, glaucoma, muscle weakness, lack of coordination, muscle wasting, and a history of falls experienced multiple falls over several months. Despite repeated incidents, there was no evidence that new interventions were implemented to prevent further falls until after several events had occurred. Additionally, staff did not complete incident reports or notify the resident's physician or responsible party following the falls, as confirmed by both the DON and the Infection Preventionist.