Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and monitor planned fall prevention interventions for a resident with end stage COPD who was receiving hospice services and had an indwelling Foley catheter. The resident was identified as being at risk for falls, and the care plan included maintaining a hazard-free environment, keeping the bed in the lowest locked position, ensuring the call bell and needed items were within reach, reinforcing call bell use, and using non-slip footwear. Despite these interventions, the resident experienced multiple falls. After the first fall, new interventions such as referrals to occupational and physical therapy and issuance of a reacher device were added. However, following the removal of the Foley catheter, nursing staff failed to complete a bladder assessment or initiate a voiding trial as recommended by the hospice nurse and physician. Subsequent falls occurred when the resident attempted to go to the bathroom without assistance, indicating that interventions such as offering toileting assistance and implementing a bowel and bladder tracker were either not documented or not effectively carried out. There was no evidence that the facility implemented or monitored the effectiveness of planned interventions, including toileting schedules, elimination tracking, and post-catheter care, to prevent repeated falls. The Director of Nursing confirmed that planned interventions were not timely implemented to prevent falls for this resident.