Failure to Reassess and Implement Fall Prevention Interventions After Hospital Readmission
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively reassess and implement interventions to reduce the risk of further falls and injury for a resident who was re-admitted from the hospital after sustaining injuries from a fall. The resident had a complex medical history, including Alzheimer's disease, multiple fractures, morbid obesity, and severe cognitive impairment. Upon return from the hospital, there was no evidence in the medical record of a fall assessment or therapy assessment being completed, despite the resident's recent injuries and high risk for falls. The care plan and progress notes did not reflect updated assessments or interventions tailored to the resident's changed condition following hospitalization. Observations and interviews revealed inconsistent and improper use of gait belts during transfers, with staff sometimes relying on the resident's clothing instead of the gait belt, and not always following proper transfer techniques. Staff interviews indicated a lack of understanding and training regarding the correct use of gait belts and the need for reassessment after a significant change in the resident's condition. Family members also reported witnessing unsafe transfer practices, such as staff transferring the resident without a gait belt and using her clothing for support, which raised concerns about the resident's safety. Facility policies required reassessment and determination of the safest transfer method after any change in condition or transfer-related incident, but these procedures were not followed after the resident's return from the hospital. The lack of timely reassessment and failure to update interventions based on the resident's current needs contributed to the ongoing risk of falls and injury. Documentation and staff interviews confirmed that required assessments and communication with therapy were not completed as expected.