Failure to Implement and Update Interventions for Falls and Skin Tears
Penalty
Summary
The facility failed to implement new interventions to prevent falls for a resident with severe cognitive impairment and multiple risk factors, despite the occurrence of three falls within a short period. The resident, who had diagnoses including Alzheimer's disease, dementia, unsteadiness, and difficulty walking, required supervision and assistance for mobility. The care plan listed several fall prevention interventions, but after the resident experienced multiple falls, no new interventions were added, and the existing interventions were simply repeated. Observations confirmed that some interventions, such as the use of a wheelchair, were not consistently in place, and staff interviews revealed that a wheelchair was not regularly used or available for the resident. Additionally, the facility did not investigate or implement interventions to prevent further skin tears for another resident who was non-ambulatory, dependent on staff for care, and receiving anticoagulant therapy. After the resident sustained a skin tear to the forearm, staff provided immediate wound care but did not complete an incident report or update the care plan with new interventions to prevent recurrence. The facility's policy required incident reporting and the implementation of preventive measures based on assessment, but these steps were not followed. Interviews with facility leadership confirmed that required post-incident assessments, care plan updates, and preventive interventions were not completed for either resident following their respective incidents. The failures were identified through record review, staff interviews, and direct observation, demonstrating noncompliance with facility policies and regulatory requirements for accident prevention and skin integrity management.