Failure to Timely Update and Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure that person-centered fall interventions were care planned and implemented for a resident at risk for falls, resulting in actual harm. The resident had multiple diagnoses, including metabolic encephalopathy, neurocognitive disorder with Lewy bodies, anxiety disorder, and severe cognitive impairment, and required assistance with all activities of daily living. The care plan identified the resident as a fall risk due to a history of falls, impaired gait and mobility, and other medical conditions. Despite this, there were lapses in updating and implementing fall prevention interventions following incidents. The resident experienced several falls, including one that resulted in a rib fracture. After a fall on one occasion, a floor mat was identified as a new intervention, but it was not added to the care plan until a later date. Similarly, after another fall, a soft touch call light was determined to be an appropriate intervention, but this was also not promptly updated in the care plan. Staff interviews revealed that not all staff were aware of the required interventions at the time of the incidents, as these were not reflected in the care plan or care guide sheets used by staff. Observations confirmed that some interventions, such as the floor mat, were not present in the resident's room at the time of a fall. Documentation and staff statements indicated that the process for updating care plans and communicating new interventions to staff was inconsistent. The interdisciplinary team (IDT) would determine interventions after reviewing incidents, but there were delays in updating the care plan and care sheets, leading to gaps in staff awareness and implementation of fall prevention measures. As a result, the resident did not consistently receive the interventions identified as necessary to prevent further falls and injury.