Failure to Update Fall Prevention Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to implement effective supervision and accident prevention interventions for a resident with a documented history of falls and multiple risk factors, including hemiplegia, hemiparesis, hypertension, and blindness. Despite the facility's policy requiring fall risk assessments and updates to the care plan after each fall, the resident experienced five separate falls over a period of several months. After each incident, including one resulting in a laceration and hematoma to the left eyebrow that required emergency department treatment, no new interventions were documented or added to the resident's care plan. Interviews with staff confirmed that the resident's bed was positioned against the wall due to his fall history, but no additional measures were taken after repeated falls. Staff also noted that the resident sometimes pushed against the wall, which may have contributed to the bed shifting and a subsequent fall. The Assistant Director of Nursing acknowledged that the facility did not initiate new interventions following the repeated falls, despite the policy and the resident's ongoing incidents.