Failure to Implement Resident-Centered Fall Prevention and Monitor Effectiveness
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident with a known history of impulsive behavior and repeated attempts to get out of bed unassisted. Despite being identified as a high fall risk with multiple diagnoses, including encephalopathy and type 2 diabetes, the resident experienced several falls over a period of months. The care plan interventions primarily consisted of standard fall prevention measures such as low bed, floor mats, bed alarms, and placement near the nurse's station, but did not include a resident-centered approach or address the specific causative factors of the resident's behavior as required by the facility's policy. The facility did not consistently monitor or document the effectiveness of the fall prevention interventions. Although the care plan called for assessment and reduction of behavioral triggers, staff interviews and record reviews revealed that the facility did not investigate or document the underlying causes of the resident's repeated attempts to self-transfer. The interdisciplinary team conferences following each fall did not result in new or individualized interventions, and the facility continued to rely on the same standard measures despite ongoing incidents. Staff acknowledged the resident's impulsiveness and need for close monitoring, but the facility did not utilize sitters or other enhanced supervision strategies. On the date of the most serious incident, the resident was found on the floor mat after the bed alarm sounded, having sustained significant injuries including fractures to both hips. Documentation indicated that frequent rounding was being performed, but there was no evidence of a comprehensive evaluation of the effectiveness of interventions or of any changes made to address the resident's persistent fall risk. The facility's failure to implement a resident-centered fall prevention plan, monitor the response to interventions, and assess causative factors contributed to the resident's repeated falls and resulting injuries.