Failure to Implement Effective Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls received adequate supervision and effective, person-centered interventions to prevent repeated falls. For one resident with a history of stroke, dementia, anxiety, and unsteadiness, the care plan included multiple interventions such as reminders to use the call light, non-skid footwear, and keeping personal items within reach. However, observations revealed that the resident's glasses and hearing aids were out of reach, the call light signage was difficult to read due to poor contrast, and the resident's wheelchair lacked proper identification. Documentation did not confirm whether the resident understood how to use the call light or if interventions were tailored to her cognitive abilities. Additionally, there was no evidence of pharmacy review specific to fall prevention, and the responsible party was not consistently involved in developing or updating fall prevention strategies. Another resident with severe cognitive impairment, muscle weakness, and a history of falls was also not provided with all required safety interventions. Although the care plan called for anti-rollback brakes on the wheelchair and other fall prevention measures, observations showed that the anti-rollback brakes were not installed as required. Staff interviews indicated a lack of awareness regarding the need for these safety devices, and progress notes documented multiple falls after the intervention was recommended but not implemented. The care plan included frequent checks and reminders, but these were not always carried out or documented as effective. Audits and performance improvement plans were in place to monitor fall prevention interventions, but these did not consistently assess the residents' specific needs or the effectiveness of interventions. For example, audits failed to evaluate whether residents could read reminder signs, reach their call lights, or use them effectively. There was also a lack of follow-through on therapy recommendations and incomplete documentation of resident preferences and abilities. As a result, the facility did not consistently implement or monitor person-centered, effective fall prevention interventions for the affected residents.