Failure to Implement Post-Fall Interventions and Care Plan Revisions
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision and interventions to prevent accidents for three residents. Despite having policies in place for falls management and post-fall protocols, the facility did not implement immediate interventions after falls, did not conduct root cause analyses, and did not update or revise care plans following fall incidents. This was observed through record reviews, interviews, and incident reports for three residents who experienced falls. One resident with severe cognitive impairment and a history of multiple falls was found on the floor with a head injury, but the incident report lacked documentation of immediate interventions or care plan updates. Another resident with hemiplegia and a history of falls prior to admission experienced a fall while attempting to put shoes away, yet the incident report did not include immediate interventions, and there was no evidence of an interdisciplinary team investigation or care plan revision. A third resident with severe cognitive impairment and a cerebrospinal fluid drainage device fell from a wheelchair, sustained a hematoma and abrasions, and was sent to the emergency department, but there was no documentation of a root cause analysis or follow-up occupational therapy evaluation as indicated in the care plan. In all three cases, the facility did not follow its own policies regarding post-fall assessment, investigation, and care plan revision. The lack of immediate interventions, root cause investigations, and care plan updates after falls contributed to the deficiency, as confirmed by the absence of interdisciplinary team notes and the statements from facility administration.