Failure to Implement and Document Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement and document fall prevention interventions for a newly admitted resident with a documented history of multiple vertebral fractures and recent falls. Upon admission, the resident's hospital discharge plan and baseline care plan both indicated a significant risk for falls, including recent compression and burst fractures, low back pain, abnormal gait, muscle wasting, and lack of coordination. Despite these risk factors, no specific goals or interventions to prevent falls were documented in the resident's baseline care plan or admission assessment. Following admission, the resident experienced two unwitnessed falls within the facility. The first fall resulted in a skin tear to the left elbow, and the second fall led to a skin tear on the right elbow and post-fall lethargy, requiring transfer to the emergency department. The resident received IV fluids and narcotic pain medication at the hospital. Nursing notes and fall reports for both incidents did not document any interventions implemented to prevent future falls, nor were any changes made to the care plan after these events. Interviews with facility staff, including the Director of Nursing, confirmed that interventions should have been documented for residents with a history of falls. The facility's Fall Prevention Program requires individualized assessment and implementation of appropriate interventions at admission and after any fall, but these measures were not followed for this resident. The lack of documented interventions and failure to update the care plan after repeated falls constituted the deficiency.