Failure to Implement Individualized Fall Prevention Leading to Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive and individualized fall prevention program for a resident with a known history of falls and multiple risk factors, including diabetes, gait abnormalities, osteopenia, osteoarthritis, anemia, lymphedema, repeated falls, and generalized muscle weakness. Despite being identified as at risk for falls upon admission and after multiple incidents, the primary intervention repeatedly used was to educate and remind the resident to call for assistance, even after several unwitnessed falls. There was a lack of evidence that more effective or individualized interventions were implemented following these incidents. The resident experienced multiple falls, some resulting in significant injuries, including a left hip fracture and a right hip fracture. On one occasion, a CNA failed to maintain hands-on contact during a transfer, resulting in the resident falling and sustaining a right hip fracture. Documentation showed that the resident continued to transfer unassisted despite being assessed as requiring staff assistance, and staff interventions remained limited to education and reminders, which were ineffective in preventing further falls. The care plan was not consistently updated with new or individualized interventions after each fall, and there was insufficient evidence that the facility addressed the resident's non-compliance with safety recommendations in a manner that reduced fall risk. Interviews with staff confirmed that the resident was impulsive and non-compliant with safety instructions, and that education was considered an adequate intervention despite repeated falls and injuries. The facility's falls policy required adequate supervision and assistance, but the actions taken did not meet these requirements, as evidenced by the continued occurrence of falls and injuries without the implementation of more effective or tailored interventions.