Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent avoidable falls for a resident with Alzheimer's/dementia and a history of multiple falls. The resident experienced five falls over a two-month period, with one incident resulting in an arm injury. Observations revealed that the resident's room was located far from the nurses' station and the door was kept completely closed, limiting staff supervision. Despite care plan revisions, interventions such as encouraging the resident to leave the door open for increased supervision were not consistently implemented, as staff confirmed they always kept the door closed, honoring the resident's preference. Record reviews indicated that after the most recent fall, staff performed neuro-checks, but the care plan was not updated to address contributing factors or to include routine visual checks. The Director of Nursing confirmed that the facility did not assess the causes of the falls or update the care plan to reduce the risk of further incidents. Facility policy requires timely assessment and increased monitoring following a fall, but these measures were not fully carried out for this resident.