Failure to Implement and Document Fall Prevention Interventions and Investigations
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented and that fall incidents were thoroughly investigated for a resident with significant risk factors. The resident, who had diagnoses including muscle weakness, artificial hip joints, dementia, depression, and glaucoma, was identified as being at risk for falls upon admission. The care plan included multiple interventions such as ensuring proper footwear, keeping the call light within reach, and laying the resident down after meals. Despite these interventions, the resident experienced multiple falls, and new interventions were added over time, including a pain medication regimen, keeping the bathroom light on at night, placing the bed in a low position, and using a bolster mattress. During the investigation of two separate falls, documentation was incomplete. For the first fall, there was no evidence that vital signs or a full body assessment were completed, nor was there documentation regarding the resident's footwear at the time of the fall. For the second fall, while vital signs were recorded, there was no documentation confirming the presence of the bolster mattress, the call light being within reach, the timing of the last toileting, use of nonskid socks, or that the bed was in the lowest position. Additionally, a fall mat intervention was not documented in the care plan or fall investigation, and staff confirmed that a bolster mattress had never been in place, despite it being listed as an intervention. Interviews with staff, including a CNA and the DON, confirmed that not all required interventions were in place and that fall investigations lacked necessary information to be considered complete and thorough. The facility's policy required that all falls be reviewed and investigated, with individualized interventions implemented and care planned accordingly. The failure to ensure interventions were in place and to conduct thorough investigations led to the deficiency cited in the report.