Failure to Consistently Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement and document care-planned supervision interventions and did not fully evaluate the effectiveness of fall prevention measures for a resident with a history of dementia, falls, and a recent femur fracture. Upon admission, the required comprehensive fall risk assessment was not completed in a timely manner, and individualized fall risk was not assessed. The resident experienced multiple unwitnessed falls, including incidents in the activity area and in their room, some resulting in significant injuries such as a hip fracture and a broken wrist. Documentation revealed that interventions such as 15-minute checks and the use of hip protectors were not consistently carried out or documented, and staff were often unclear about the specific interventions required for the resident. Observations and interviews indicated that staff did not always follow the care plan interventions, such as ensuring the resident wore hip protectors while in bed and performing 15-minute checks as ordered. There were repeated omissions in the documentation of these checks, and staff interviews confirmed that if checks were not documented, they were likely not performed. Additionally, staff were sometimes unaware of the location or use of hip protectors, and there was confusion regarding the frequency and nature of required supervision. The resident was able to move their fall mat and alarm, and staff acknowledged that the resident did not reliably use the call light, further increasing the risk of falls. Incident reports for several falls lacked thorough investigation, staff statements, or documentation of the circumstances leading to the falls. The care plan was not always updated promptly after incidents, and there was no evidence that the effectiveness of interventions was systematically evaluated following each fall. Staff interviews revealed uncertainty about the process for updating care plans and communicating changes, and there were lapses in ensuring that all staff were aware of and implementing the required interventions. These failures placed the resident at continued risk for accidents and injury.