Failure to Revise and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement, review, and revise fall prevention interventions for two residents with a history of falls, resulting in repeated falls and injury. One resident, who was severely cognitively impaired and had recently been evaluated by physical therapy, experienced a change in transfer status but this was not updated in the care plan. After a fall that resulted in a hip fracture, there was no evidence that new or revised interventions were implemented or documented, and the care plan was not updated to reflect changes in transfer needs or fall prevention strategies. Additionally, the resident's admission to hospice and the need for an air mattress overlay were not reflected in the care plan, and recommended interventions such as increased toileting were not added after previous falls. Another resident, also severely cognitively impaired with multiple neuropsychiatric diagnoses, experienced at least 15 falls over a two-month period, including four falls in a single day. Video footage showed that after each fall, the resident was returned to the same position without new interventions to prevent further incidents. Staff did not consistently document or implement new fall prevention measures after each event, and the care plan was not updated with additional interventions despite repeated falls. Some incident reports lacked any documented interventions, and post-fall investigation tools were often incomplete. Interviews with staff revealed a lack of training and uncertainty about where to find or how to update fall interventions in the electronic medical record. While there was an expectation from management that care plans be updated in real time after a fall, staff reported not receiving education on this process and not routinely referencing the care plan for fall interventions. The facility's policy required interdisciplinary review of falls and implementation of new interventions, but this was not consistently followed in practice.