Failure to Prevent Accidents and Update Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that the environment was as free from accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents for five residents. Multiple residents experienced repeated falls or accidents without consistent or effective updates to their care plans or interventions. For example, one resident with Alzheimer's disease and a history of falls experienced several falls, some resulting in injury, while wandering unsupervised or attempting to get out of bed. Despite these incidents, care plan interventions were not always updated after each fall, and staff interviews revealed inconsistent use of alarms and supervision. Observations also showed that staff were not always present to assist the resident, and family members reported delayed staff response to call lights. Another resident with a traumatic brain injury, right-sided weakness, and poor safety awareness experienced multiple falls, including incidents in the bathroom and during transfers. The care plan for this resident was not consistently updated with new interventions after each fall, and some interventions, such as the use of a knee brace or non-slip footwear, were not always implemented. Staff interviews indicated that there was confusion or lack of awareness regarding specific interventions, and observations revealed that the resident's bed was not always kept in the lowest position and that appropriate footwear was not always used. The facility's QAPI documentation acknowledged an increase in falls and identified issues with implementing interventions, but falls with injuries continued to occur. A third resident, who was cognitively intact but had a history of falls and a recent fracture, also experienced falls without new interventions being added to the care plan. After a fall resulting in a tibial plateau fracture, the resident continued to use a wheelchair, but the care plan did not reflect any new strategies to prevent further incidents. Documentation showed that education on using the call light was provided, but this intervention had been in place for years and was not newly implemented in response to the recent falls. Overall, the facility did not consistently update care plans or implement new interventions after repeated accidents, and staff were not always aware of or following existing interventions.