Failure to Implement and Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to provide effective fall prevention and adequate supervision for a resident with a documented history of frequent falls and severe cognitive impairment. This resident experienced 50 falls over an eight-month period, many resulting in injuries such as hematomas, lacerations, and head injuries, some of which required emergency room visits. Despite being identified as a high fall risk and having multiple interventions listed in the care plan, staff did not consistently implement or update these interventions after each fall, and several falls were not addressed in the care plan at all. Additionally, fall risk assessments were not completed after every incident as required by facility policy. Observations and interviews revealed that staff often failed to keep the resident's call light within reach, did not maintain the resident in visible areas for supervision, and did not follow specific care plan interventions such as increased toileting rounds or ensuring environmental safety (e.g., removing nightstands, keeping doors open for visual checks). On multiple occasions, the resident was found lying on the floor or in bed with saturated linens, indicating a lack of timely assistance with activities of daily living and incontinence care. Staff were observed opening the resident's door to check if he was breathing but did not provide further care or ensure his safety, and transfers were performed without the use of gait belts or proper technique, increasing the risk of falls and injury. Interviews with facility leadership and clinical staff confirmed that there was an expectation for staff to follow all care plan interventions and maintain resident safety, but these expectations were not met. The facility's own policies required prompt response to resident needs, regular fall risk assessments, and implementation of individualized interventions, none of which were consistently followed. The failure to implement and monitor effective fall prevention strategies and provide adequate supervision directly resulted in repeated injuries and placed the resident in Immediate Jeopardy.
Removal Plan
- A fall risk assessment was completed for R2 and placed on 1:1 supervision.
- 1:1 sitters were in-serviced on 1:1 expectation related to coordination of care for R2.
- IDT team reviewed R2 falls to ensure that appropriate current interventions are in place.
- Facility Administrator, DON, ADON, MDS Coordinator were in-serviced on Fall Prevention Policy.
- In-service front-line staff on Fall Prevention Policy and where to verify Care Plan Interventions.
- In-serviced Nursing staff on how to find care plan/fall interventions in EHR. Staff will not work next shift until Fall Prevention In-service is completed.
- An initial audit will be completed of all falls to ensure current interventions are initiated and effective. Care plans will reflect interventions that are effective.
- Initial audit completed of fall risk assessments to ensure that appropriate prevention interventions are in place and care plans are reflecting those interventions.
- A quality assurance tool was implemented: An audit will be completed during clinical meeting to ensure that any fall has a root cause analysis, progressive intervention, and care plan is updated.
- A root cause analysis for Fall Prevention and interventions being placed on care plan and physically in place will be reviewed weekly during Facility Risk Meeting.
- Review of the Fall Prevention Policy.