Delayed Implementation of Fall Prevention Interventions After Resident Injury
Penalty
Summary
The facility failed to ensure timely implementation of care plan interventions following a resident's fall with injury. A resident with diagnoses including anxiety, dementia, history of falls, weakness, and insomnia, and with moderately impaired cognition, experienced an unwitnessed fall resulting in fractures to both femurs. Prior to the fall, the care plan identified the resident as at risk for falls and directed staff to place the call bell within reach and provide assistance with bed mobility. However, after the fall, the care plan was not promptly updated with new interventions to prevent further falls. Although pain management was added to the care plan after the incident, an intervention to use a bolster mattress was not included until two days after the fall, and the mattress itself was not applied until four days after the incident. Interviews with facility leadership confirmed that the care plan should have been updated and interventions implemented sooner, but no explanation was provided for the delay. The deficiency centers on the lack of timely care plan revision and delayed implementation of fall prevention measures following a significant injury event.