Failure to Investigate and Prevent Repeated Resident Falls
Penalty
Summary
The facility failed to adequately investigate resident falls and to timely develop and implement effective safety interventions for residents with a known history of falls and unsafe behaviors. For one resident with hemiplegia, legal blindness, and end-stage heart disease, the care plan identified fall risk and included general interventions such as education, keeping the environment free of clutter, and therapy evaluation. Despite these measures, the resident experienced ten falls within a one-month period, including both witnessed and unwitnessed incidents, resulting in injuries such as bruising, abrasions, and skin tears. Documentation showed the resident exhibited anxiousness, self-ambulation, aggression, and disruptive behaviors, but the facility did not identify root causes or implement enhanced supervision or individualized interventions, leading to repeated falls. Another resident with dementia, diabetes, and hypertension, who was non-ambulatory and required two staff for transfers and toileting, also experienced multiple unwitnessed falls. The care plan included general fall prevention interventions and a bariatric bed bolster overlay, but did not specify toileting frequency or address continence needs. The resident sustained four falls over a two-month period, with documentation lacking root cause analyses or individualized interventions after each incident. One of these falls resulted in a serious injury—a comminuted distal femoral fracture—requiring hospitalization and pain management. Interviews with facility staff, including the Assistant Director of Nursing and a corporate nurse consultant, confirmed that falls were not adequately investigated and that interventions were ineffective or not individualized. There was no evidence that the facility conducted thorough root cause analyses or developed and implemented specific interventions tailored to the residents' needs, resulting in repeated falls and, in one case, a serious injury.