Failure to Implement Fall Prevention and Post-Fall Monitoring
Penalty
Summary
The facility failed to implement fall prevention interventions and conduct post-fall monitoring for a resident identified as high risk for falls. The resident had diagnoses including anxiety, muscle weakness, and high blood pressure, and was assessed as having severe cognitive impairment and requiring substantial assistance with toileting and transfers. The care plan specified the use of bed/chair alarms and assistance with toileting every two hours, but these interventions were not consistently implemented. An incident occurred in which the resident fell in the bathroom while attempting to transfer from the toilet to the wheelchair without adequate staff assistance. The fall resulted in a skin tear and complaints of dizziness and headache. Although the facility's policy required immediate physical assessment, timely documentation, and prompt initiation of neurological checks after a fall, these actions were not completed as required. Neurological checks were not started until nearly a day after the fall, and there was no evidence of a timely physical assessment or Q15 minute checks in the clinical record. Additionally, there were significant delays in notifying the resident's family and physician about the fall, with the family being notified 20 days later and the physician three days after the incident. Staff interviews confirmed that required assessments and documentation were not completed promptly, and that staff were unclear about their responsibilities regarding post-fall monitoring and communication. These failures resulted in noncompliance with facility policy and state regulations regarding accident prevention and resident care.