Failure to Implement Fall Interventions and Complete Accurate Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that fall interventions were consistently implemented and that post-fall assessments were accurately completed for three residents identified as being at high risk for falls. One resident, with severe dementia and a history of falls, had a care plan intervention requiring two body pillows in bed for comfort and safety, but was observed with only one pillow in use, while the second was left on a chair. The certified nursing assistant responsible was unaware of the need for a second pillow, indicating a lack of communication or training regarding the resident's care plan. Additionally, post-fall assessments for all three residents were not completed according to facility policy. The assessments often contained vital signs and pain evaluations that were either outdated or taken from other time periods, rather than being obtained at the time of each assessment as required. The Director of Nursing confirmed that staff had likely missed assessments and completed them in batches, sometimes using old or future-dated vital signs, which did not meet the policy's requirements for monitoring residents after a fall. The facility's own policies required individualized interventions to be implemented and post-fall assessments to be documented every shift for 72 hours, including relevant clinical findings such as vital signs, pain, and changes in function or cognition. However, the review of medical records and staff interviews revealed that these procedures were not followed, resulting in incomplete monitoring and documentation for residents who had experienced falls.