Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement effective interventions to prevent a serious fall-related injury for a resident with multiple risk factors, including a history of traumatic brain injury, ataxia, epilepsy, schizophrenia, and moderate cognitive impairment (BIMS score of 10). The resident was known to be non-compliant with wearing a protective helmet and had a documented behavior of repeatedly getting out of bed despite education. At the time of the incident, the resident was not under 1:1 supervision or assigned a sitter, and was housed in a room far from the nurse's station, making monitoring difficult. The resident was found on the floor in the hallway with an open area to the back of the head and was subsequently diagnosed with a subarachnoid hemorrhage and required staples to the head. Staff interviews revealed uncertainty regarding when and why 1:1 supervision or sitter services were discontinued, and the falls care plan did not include close monitoring as an intervention. The resident's helmet was often not worn correctly or at all, and staff acknowledged that re-education was likely ineffective due to the resident's cognitive status. Documentation did not clarify the rationale for changes in supervision, and there was no evidence of alternative or additional interventions being implemented to address the resident's ongoing fall risk and non-compliance with safety measures.