Failure to Implement Post-Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement an intervention to prevent further falls after a resident experienced a fall resulting in a serious injury. The resident had multiple diagnoses, including severe cognitive impairment, a nonunion femur fracture, muscle weakness, anxiety, and a history of frequent falls. The resident required extensive assistance for transfers and mobility, including the use of a mechanical lift and wheelchair. Despite being identified as high risk for falls and having several care plan interventions in place, after a significant fall in which the resident was left unattended in the dining room and sustained a femur fracture, the facility did not document or implement any new intervention to prevent further falls. Staff interviews revealed that interventions following falls were not consistently chosen by direct care staff and that the interventions in place were considered inadequate by some staff members. Additionally, there was a lack of documentation for previous fall investigations, and the process for reviewing and updating interventions was not consistently followed. The facility's policy required completion of an occurrence report, root cause determination, and implementation of interventions after each fall, but these steps were not fully carried out in this case.