Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place for a resident identified as high risk for falls. The facility's Fall Prevention Program policy outlines the need for individualized assessment and implementation of appropriate interventions, but in this case, the resident's care plan only included ensuring appropriate footwear and did not address other necessary fall prevention measures. Multiple staff members, including CNAs and nursing staff, confirmed that no additional fall interventions were in place, aside from occasionally placing the bed in a low position. The care plan coordinator acknowledged that more interventions should have been included, and the regional nurse consultant cited an IT issue that contributed to the lack of interventions. The resident had a medical history of repeated falls, weakness, and partial paralysis on one side of the body following a stroke, and was assessed as high risk for falls. The Minimum Data Set (MDS) assessment indicated the resident required partial to moderate assistance with toileting hygiene. Despite these risk factors, the resident was found on the bathroom floor by a CNA, and subsequent medical evaluation revealed multiple left-sided rib fractures, a collection of blood in the chest cavity, and a collapsed lung. The resident's condition worsened, as documented by follow-up imaging. Interviews with staff confirmed that the resident was known to be at high risk for falls, but there was a lack of communication and implementation of fall prevention interventions. The Director of Nursing and the former Medical Director both stated that having proper fall protocols and precautions in place could have changed the outcome for the resident. The deficiency was attributed to the failure to assess and implement appropriate fall prevention measures as required by the facility's own policy.