Failure to Implement Effective Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the environment was as free from accident hazards as possible and did not provide adequate supervision or implement new interventions to prevent accidents for two high fall risk residents. One resident with multiple diagnoses including dementia, muscle weakness, morbid obesity, and unsteadiness on feet was documented as a high fall risk and experienced several falls within a short period. Despite being a full assist and having a history of falls, no new fall prevention interventions were documented in the medical record after each incident. Staff interviews confirmed that no additional interventions were implemented, and the resident was not on continuous observation, even though the resident had fallen multiple times in a short timeframe and was ultimately sent to the hospital after a change in condition. Another resident with epilepsy, brain deformity, unsteadiness, and muscle weakness was also identified as a high fall risk and experienced multiple falls over several months. After each fall, the interventions implemented were often repeated or limited to education and minor environmental changes, such as providing a non-slip mat or instructing on proper footwear. Despite the resident's cognitive delays, impulsivity, and difficulty following instructions, the interventions did not change significantly after repeated falls, and the care plan was not sufficiently updated to address the ongoing risk. Interviews with nursing staff and consultants revealed that both residents required frequent prompting and supervision due to their cognitive and physical limitations. However, the facility did not implement new or different interventions after repeated falls, and the care plans were not adequately revised to prevent further incidents. The lack of timely and appropriate updates to interventions and care plans contributed to the deficiency in maintaining a safe environment and providing adequate supervision for these high-risk residents.