Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow its fall prevention policy and implement individualized, resident-centered interventions for a cognitively impaired resident identified as high risk for falls. The resident, who had diagnoses including end stage renal disease, unsteadiness on feet, gait abnormalities, and atherosclerotic heart disease, was assessed as having severely impaired cognitive skills and required supervision or assistance when ambulating. Despite these documented needs, the resident was able to ambulate unsupervised, resulting in an unwitnessed fall in the hallway during the night. Staff interviews and record reviews revealed that the resident was confused, unable to use the call light, and required frequent redirection and monitoring. Care plans indicated the need for staff assistance with ambulation, use of electronic alarms, and regular monitoring. However, at the time of the incident, the resident did not have a chair or bed alarm in place, and staff monitoring was not conducted at the frequency specified in the care plan. The CNA on duty was the only staff present on the resident's wing and was not actively supervising the resident when the fall occurred. The fall resulted in the resident sustaining a right intertrochanteric hip fracture with associated intramuscular hemorrhage, requiring hospital admission. Documentation and staff statements confirmed that the facility did not consistently implement the individualized interventions outlined in the care plan, such as ensuring the use of alarms and providing the required level of supervision for a resident with significant cognitive impairment and high fall risk.