Failure to Assess and Prevent Falls Resulting in Major Injury
Penalty
Summary
The facility failed to comprehensively assess falls for root cause, implement appropriate interventions, and update or revise care plans to prevent or reduce the risk of falls with major injury for two residents who experienced multiple falls. One resident, with a history of stroke, hemiplegia, and cognitive impairment, experienced several unwitnessed falls, including one that resulted in a subarachnoid hemorrhage and hospitalization. Despite documented risk factors such as impulsivity, incontinence, and poor safety awareness, the resident's care plan was not consistently updated to reflect these risks or to include interventions recommended by therapy staff. Incident reports and progress notes repeatedly lacked evidence of comprehensive fall investigations or causal analyses, and interventions such as supervision, use of fall mats, and toileting schedules were either not implemented or not documented in the care plan. Another resident, diagnosed with Huntington's disease and a history of falls, also experienced multiple unwitnessed falls. The care plan for this resident identified high fall risk but did not include specific interventions tailored to the resident's needs, such as regular toileting or ensuring the call light was within reach. After each fall, there was no indication that a comprehensive analysis was conducted to identify causal factors, nor was the care plan revised to address the circumstances of the falls. Documentation was inconsistent, and staff interviews revealed a lack of awareness regarding current fall prevention interventions for these residents. Staff interviews further revealed that nursing assistants and other clinical staff were often unaware of the specific fall prevention interventions in place for high-risk residents. There was confusion about where to find care plan information, and some staff were not trained on how to update care plans or conduct root cause analyses after falls. The facility's own policy required individualized, resident-centered fall prevention plans and prompt documentation and care plan updates after each fall, but these procedures were not followed, resulting in repeated falls and a major injury for one resident.
Removal Plan
- R1 had an updated fall risk assessment completed.
- R1's falls had a root cause analysis and appropriate fall prevention interventions added to the clinical chart.
- Interdisciplinary team reviewed R1's falls and root cause analysis to ensure appropriate fall interventions in place based on resident needs and resident's status based on the individual falls and root cause analysis.
- R1's care plan updated to include current fall interventions and fall risk level.
- All high risk fall residents who had a fall had a root cause analysis completed and care plans were updated to remove/negate the risk of falls based on potential risks of falls.
- Staff were re-educated on the facility's falls and fall risk, managing, fall risk assessment, assessing falls and their causes, falls-clinical protocol, baseline care plan, and comprehensive care plan policies.
- All clinician staff was re-educated on the facility policies, ensuring licensed staff adding immediate intervention post fall, updating care plan.
- Agency nursing staff orientation checklist update to include education on fall prevention policies and procedures.