Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to review, revise, and implement care plan interventions to prevent falls for a resident with severe cognitive impairment, limited range of motion on one side, and dependence on staff for ambulation, transfers, and toileting. The resident had multiple diagnoses, including non-Alzheimer's dementia, anxiety, and depression, and experienced several falls over a one-month period. Despite the facility's policy requiring proactive fall prevention, post-fall assessment, and care plan updates, there was no documentation that interventions were put in place after each fall. Record reviews showed that after each fall, there was no evidence of new or revised interventions to prevent future incidents, and the resident's care plan was not updated accordingly. The DON confirmed that interventions to prevent future falls were not implemented following each event, and the care plan should have been updated as per facility policy. This deficiency was identified through record review and staff interview.