Failure to Update and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and update appropriate interventions to prevent continued falls among multiple residents with known fall risks and histories of previous falls. For one resident with multiple complex diagnoses and a history of falls, staff were instructed not to leave the resident alone in their room and to keep them near the nurse's station, but the resident experienced repeated falls in their room, indicating that interventions were not consistently followed or updated. Another resident with a history of repeated falls and a recent fall with injury was observed with their bed positioned away from the wall, contrary to their care plan instructions for safety, and staff acknowledged that the care plan interventions needed revision. Additional residents with fall histories did not have new interventions added to their care plans after experiencing actual falls. One resident fell after attempting to close window blinds without staff assistance, despite being at moderate risk for falls and requiring appropriate footwear. Another resident, dependent on staff for transfers and with paralysis, fell after being placed incorrectly in a wheelchair, resulting in the wheelchair tipping over. In both cases, staff confirmed that no new interventions were documented following the falls, contrary to facility policy requiring evaluation and modification of plans after such incidents.