Failure to Implement and Maintain Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for a cognitively impaired resident with a history of repeated falls. The resident, diagnosed with hydrocephalus, dementia, type II diabetes, and essential hypertension, experienced 11 falls over several months. Despite being identified as a high fall risk, the resident's care plan interventions, such as keeping essential items within reach, ensuring a working and accessible call light, providing appropriate footwear, and activating a bed alarm, were not consistently implemented. On multiple occasions, fall interventions were missing or not updated following each fall, contrary to facility policy. Direct observations and interviews revealed that the resident was left unsupervised, with the call light tangled and out of reach, the bed alarm not activated, and essential items like water and tissues not accessible. Staff acknowledged that the bed alarm was not turned on and that the call light should have been within reach. The resident was also observed walking around the room in socks, which was not in accordance with the care plan specifying appropriate footwear. Activity interventions were not provided as required, and the resident was not engaged in activities despite this being a listed intervention for fall prevention. Documentation and staff interviews confirmed that the facility's fall prevention policy, which requires individualized interventions after each fall and consistent implementation of care plan measures, was not followed. The resident continued to experience falls, some resulting in hospital evaluations, and staff admitted to not always being able to provide the required level of supervision. The deficiency was further substantiated by the lack of timely updates to the care plan and failure to ensure all interventions were in place after each incident.