Failure to Revise Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to revise fall prevention interventions for a resident with a history of dementia, lack of coordination, and difficulty walking, who was identified as being at high risk for falls. Despite multiple documented falls and a high fall risk score, the resident's care plan and fall risk assessments were not updated with new or revised interventions after a subsequent unwitnessed fall. The care plan continued to include interventions such as keeping the call light within reach and reminding the resident not to get up without assistance, which staff acknowledged were ineffective due to the resident's cognitive impairment. On the date of the incident, the resident experienced an unwitnessed fall and was found on the floor, prompting a transfer to an acute care hospital for evaluation. Medical imaging at the hospital revealed no acute injuries, but the resident was classified as high risk for further falls due to age and dementia. Interviews with facility staff, including a CNA, LVN, RN Supervisor, and DON, confirmed that the care plan was not appropriately revised to address the repeated falls, and that interventions remained unchanged despite evidence they were not effective for this resident's condition. Facility policies required ongoing assessment and revision of care plans as residents' conditions changed, and specifically called for re-evaluation and modification of interventions if falls continued. However, the staff practice was to create new care plans for each fall incident without revising existing interventions, resulting in a lack of effective, individualized fall prevention strategies for the resident. This failure to update and individualize the care plan contributed to the resident's repeated falls and the associated risks.