Failure to Implement Fall Prevention Interventions and Inadequate Post-Fall Response
Penalty
Summary
Facility staff failed to implement required interventions for fall prevention for two residents, resulting in deficiencies related to accident hazards and supervision. In one case, a resident with a right below-the-knee amputation and multiple comorbidities, including heart failure, diabetes, and muscle weakness, was assessed as requiring a two-person assist for all activities of daily living (ADLs), including bed mobility. Despite this, only one staff member assisted the resident during incontinence care, leading to the resident rolling off the bed and sustaining a right distal femoral fracture. Documentation confirmed that the care plan and CNA Kardex both specified a two-person assist, but this was not followed. Additionally, there was no evidence of a thorough investigation into the fall with serious injury, as required by facility policy. Staff interviews revealed inconsistent communication and understanding of care requirements for new admissions and readmissions. While some staff stated that care plans and Kardexes are used to inform CNAs of resident needs, the involved CNA did not follow the two-person assist directive. Witness statements and interviews indicated that the incident was not properly documented in the risk management system, and the required accident report was not completed. The facility's fall management policy mandates assessment, documentation, and implementation of individualized interventions, but these steps were not adequately performed in this case. In a separate incident, another resident experienced two falls within a four-month period. After each fall, there was no evidence in the clinical record or care plan that staff addressed or implemented new interventions to prevent future falls. Interviews with staff confirmed that interventions such as increased monitoring and toileting should be implemented post-fall, but the records did not reflect any such actions. The lack of follow-up and failure to update care plans or implement preventive measures contributed to the ongoing risk of falls for this resident.