Failure to Implement and Update Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision, monitoring, and individualized care planning to prevent avoidable falls for two residents identified as high risk. One resident, with diagnoses including throat cancer and dementia and moderate cognitive impairment, was admitted without a fall prevention care plan in place despite being assessed as high risk. This resident experienced multiple falls over several days, yet no care plan or interventions were implemented until after the third fall. Additionally, there was no investigation completed for one of the falls, and the facility's records did not reflect any updates or interventions following the initial incidents. Another resident, with a history of stroke and severe cognitive impairment, also experienced multiple falls. Investigations revealed that the resident's ordered wheelchair cushion, intended as a preventive measure, was not in place at the time of each fall. Although the care plan was reportedly updated to address this, the records showed no actual updates or interventions implemented after the falls. The facility's Director of Nursing Services acknowledged that the required fall prevention processes, including care plan development and revision, were not followed for these residents.