Failure to Implement and Document Fall Prevention Interventions and Investigations
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls was adequately protected from accident hazards and that appropriate supervision and interventions were consistently implemented. Despite the resident's documented history of dementia, gait abnormalities, impulsivity, and multiple falls, the facility did not maintain required fall prevention interventions as outlined in the care plan. Observations revealed that the resident's bed was not in the lowest position, the perimeter mattress was not in place, and bilateral enabler bars were missing, even though nursing documentation indicated these interventions were present. The facility also failed to conduct and document thorough investigations following several unwitnessed falls, including a significant incident that resulted in a right femur fracture and subsequent hospitalization for surgical repair. Progress notes and care plan reviews did not include root cause analyses for the falls or specify whether all prescribed interventions were in place at the time of each incident. Additionally, there was no documentation provided for the investigation of the fall that led to the femur fracture, despite requests from the survey team and concerns raised by the resident's responsible party. Staff interviews confirmed a lack of awareness and oversight regarding the implementation of fall prevention measures. The DON was unaware that certain interventions, such as the perimeter mattress, were part of the resident's care plan, and acknowledged that documentation in the Medication Administration Record did not reflect the actual status of interventions. The Administrator also confirmed the absence of investigation documentation for the critical fall event and did not address the incident in a subsequent abuse/neglect investigation, citing a change in facility administration.