Failure to Implement and Document Fall Prevention and Behavioral Interventions
Penalty
Summary
The facility failed to develop and implement appropriate interventions to address resident behaviors and prevent recurring injuries following falls. In one case, a resident with moderate cognitive impairment, impaired mobility, and a history of impulsive behaviors experienced an unwitnessed fall that resulted in a coccyx fracture. The care plan for this resident included 15-minute safety checks and reminder signs to call for assistance before getting up, but there was no documentation that these interventions were in place or followed at the time of the fall. Staff were unable to confirm when the resident was last checked or who last observed her prior to the incident, and there was no evidence that the required reminder signs were posted in her room or bathroom. The facility's investigation did not include critical information such as the timing of the last staff check or the resident's activity prior to the fall. In another case, a resident with severe cognitive impairment, schizophrenia, and a history of putting his fingers in his mouth suffered a traumatic partial amputation of his fingertip after a witnessed fall. The injury occurred when the resident had his finger in his mouth during the fall, resulting in a severe bite injury that required surgical amputation. Despite a known history of this behavior, the resident's care plan did not include specific interventions to address or prevent the behavior of putting fingers in his mouth or nose. Staff interviews confirmed that the only action taken was to verbally remind the resident to stop, and no formal interventions or care plan updates were implemented prior to the injury. The facility's investigative files for both incidents lacked comprehensive documentation of circumstances surrounding the falls, including corrective actions and follow-up information. The absence of documented interventions and failure to implement or monitor existing safety measures contributed to the residents experiencing significant injuries. The facility did not ensure that accident hazards were minimized or that adequate supervision and interventions were provided to prevent accidents and injuries for residents at risk.