Failure to Implement Timely and Appropriate Fall Prevention for High-Risk Resident
Penalty
Summary
A resident with a history of falls, cognitive impairment, and multiple high-risk medications was admitted to the facility and experienced several unwitnessed falls, one of which resulted in a head injury requiring emergency care. Despite documented risk factors such as previous falls, use of opioids, anti-anxiety, and antidepressant medications, and significant physical and cognitive deficits, the facility failed to timely identify and implement appropriate fall prevention interventions. The resident's care plan did not include a fall prevention focus for over six weeks after admission, and interventions were not consistently updated or individualized following each fall. The facility's assessments and documentation were inconsistent and incomplete. Fall risk evaluations repeatedly scored the resident as moderate/low risk, even after multiple falls, and did not reflect the resident's actual fall history or changes in condition. There was a lack of timely and accurate care planning, with missing or backdated assessments and omitted interventions related to the resident's medication regimen and fall risk. Staff interviews revealed that supervision practices were inadequate, with residents, including the affected individual, left unsupervised in wheelchairs near the nurses station, especially during busy periods such as medication pass and shift changes. Family members and staff expressed concerns about the lack of supervision and the resident's inability to use the call light due to cognitive impairment. The care plan interventions, such as encouraging call light use, were not appropriate for the resident's condition. The facility did not have a formal falls prevention program, and communication among staff regarding fall risks and interventions was informal and insufficient. These failures resulted in actual harm to the resident, who suffered a fall with injury.