Failure to Assess, Document, and Prevent Falls for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to thoroughly assess injuries following falls, determine the root cause of falls, and develop effective interventions to prevent further falls for a resident with Alzheimer's dementia and a history of falls. The resident, who was non-ambulatory, dependent on staff for all activities of daily living, and receiving hospice care for end-stage dementia, was repeatedly observed seated in a Broda chair without a pillow, despite care plan interventions and hospice recommendations. Staff were often not present or attentive while the resident was in common areas, and the resident was able to sit up and lean forward in the chair, which contributed to her falling out of the chair and sustaining injuries, including a nosebleed and bruising around the eye. After the fall, documentation was incomplete and inconsistent. There was no documentation of the resident's bruise to her right eye, and required neurological checks were not completed according to facility policy. The care plan was not updated to include the hospice intervention of placing a pillow in front of the resident while seated at a table, and staff were unaware of this intervention. Additionally, hospice nurse notes were not available in the resident's chart, hindering coordination of care between hospice and facility staff. Interviews with staff revealed a lack of awareness regarding the resident's required interventions and inconsistent follow-through with post-fall assessments and documentation. The facility's policy required thorough assessment, documentation, and care plan updates following falls, but these steps were not consistently followed. The failure to implement and document effective interventions, assess injuries, and update care plans contributed to the deficiency cited by surveyors.