Failure to Implement and Monitor Effective Fall Interventions
Penalty
Summary
A deficiency occurred when the facility failed to adequately evaluate, implement, and monitor the effectiveness of fall interventions for a resident with a history of falls, dementia with agitation, and severe cognitive impairment. The resident required substantial assistance for mobility, was assessed as a high fall risk on multiple occasions, and had a care plan that included interventions such as bed and chair alarms, fall mats, and keeping the bed in the lowest position. Despite these interventions, the resident experienced multiple falls, including a final incident resulting in severe injuries such as a depressed skull fracture, orbital and maxillary fractures, scalp laceration, and multiple brain hematomas. Staff interviews and record reviews revealed that the alarms intended to alert staff to the resident's movements were not effective, as the resident was able to turn them off. The care plan was not consistently updated to reflect the resident's changing needs or the ineffectiveness of certain interventions. For example, the use of a self-release belt was not documented as added to the care plan, and the bed and chair alarms, as well as the fall mat, were already in place prior to the final fall but were not effective in preventing the incident. Staff also reported that the resident was often left unsupervised in her room, and the visual indicator for high fall risk was not present outside her door at the time of the incident. Observations and interviews further indicated that the resident was found on the floor with significant injuries, and the alarms did not sound at the time of the fall. The facility did not have a formal alarm policy, and staff acknowledged that the interventions in place were not always appropriate or effective for the resident. The lack of effective monitoring and adaptation of interventions contributed to the resident's ability to attempt to get out of bed unassisted, ultimately resulting in a fatal fall.