Failure to Implement New Interventions and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to implement new interventions after falls and did not complete thorough post-fall assessments for three residents with a history of falls. For one resident with dementia, cerebral infarction, and hemiplegia, documentation after an unwitnessed fall was incomplete, with several relevant risk factors such as medication use, impaired vision, and participation in restorative programs not assessed or marked. The care plan intervention added after the fall was not substantially different from existing interventions, and the interdisciplinary team did not identify or implement a new, individualized approach. Another resident with dementia, anxiety, and a thoracic spine fracture experienced an unwitnessed fall, but the post-fall assessment form was inadequately completed, omitting key risk factors such as osteoporosis, pain, and use of anti-hypertensive medication, all of which were present in the resident's medical record. Environmental and situational factors were also not assessed. The care plan referenced a floor bed and mat, but the resident was observed with a regular bed, and the intervention added after the fall was generic and not clearly linked to the specific circumstances of the incident. A third resident with Alzheimer's disease, gait abnormalities, and osteoporosis also had an unwitnessed fall. The post-fall assessment lacked documentation of environmental, physiological, and situational risk factors, and the facility was unable to provide evidence of a 72-hour monitoring assessment as claimed by the DON. The facility's fall prevention policy requires individualized assessment and immediate changes in interventions after falls, but these requirements were not met for the residents reviewed.