Failure to Follow Fall Prevention Program and Care Plan Interventions
Penalty
Summary
The facility failed to follow its Fall Prevention Program policy, resulting in inadequate prevention of fall incidents and failure to implement care plan interventions for residents assessed as moderate and high risk for falls. One male resident with multiple complex diagnoses, including chronic osteomyelitis, diabetes, chronic kidney disease, and congestive heart failure, experienced two falls in the dialysis unit. Despite being identified as moderate risk for falls upon admission and high risk after the first incident, the resident was not adequately supervised or assisted during dialysis treatments. Both falls occurred when the resident, experiencing leg cramps, attempted to get up without staff assistance after expressing his need to move. Staff were either occupied with other patients or not immediately present at the chair side, and the care plan intervention to reinforce education about not getting up unassisted was not effectively implemented. Another female resident with severe cognitive impairment, Alzheimer's disease, and multiple comorbidities also experienced a fall. She was found on the floor in a prone position after attempting to walk toward staff while wearing improper footwear. Her care plan included an intervention to ensure she wore appropriate footwear or nonskid socks when ambulating or mobilizing in a wheelchair, but at the time of the incident, she was wearing slippers, which contributed to her fall. The staff identified the root cause as the resident not wearing appropriate footwear, despite this being a documented intervention in her care plan. The facility's Fall Prevention Program policy outlines the need for individualized risk assessment, implementation of appropriate interventions, and ongoing monitoring to ensure effectiveness. However, in both cases, the facility did not ensure that care plan interventions were followed or that adequate supervision and preventive measures were in place, resulting in falls for residents at known risk. Documentation and communication lapses were also noted, with staff repeating verbatim documentation and not ensuring interventions were updated or effectively communicated to all care providers.