Failure to Implement and Document Post-Fall Interventions and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to implement and document appropriate interventions following a resident's fall. The resident, who had diagnoses including dementia, Alzheimer's disease, muscle weakness, and difficulty walking, was identified as high risk for falls upon admission. On the day of the incident, the resident was left at the entrance of the dining room by a CNA who then clocked out. Shortly after, the resident was found on the floor, having fallen, with no staff witnessing the actual fall. Following the fall, the facility did not develop or update a care plan with interventions specific to the incident. The Fall Risk Evaluation was not updated after the event, and there was no documentation of 72-hour post-fall monitoring as required by facility policy. The Change of Condition (COC) assessment and care plan updates were not completed until several days after the fall, rather than during the same shift or the following day as expected. Additionally, there was no documented evidence that the physician or responsible representative were notified at the time of the incident. Facility policy required immediate and thorough documentation, including a complete body check, notification of the physician and family, care plan entry, and post-fall assessment, none of which were completed in a timely manner. The lack of prompt assessment, documentation, and intervention following the fall placed the resident at risk for further incidents and did not ensure adequate supervision or accident prevention.