Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to provide and implement adequate preventative measures and interventions to prevent falls for a resident with a history of repeated falls and multiple complex medical diagnoses, including Alzheimer's disease, dementia, cirrhosis, heart failure, and reduced mobility. The resident was assessed as having severely compromised cognition and required partial to moderate assistance with transfers and ambulation. Despite being identified as a high fall risk, the care plan interventions were inconsistently implemented, and several falls occurred without new or revised interventions being added to the care plan after each incident. Documentation revealed that the resident experienced multiple falls over a period of time, some of which resulted in injuries such as abrasions and skin tears. Several falls were unwitnessed, and in some cases, the resident was unable to recall or communicate the circumstances of the fall. Observations by surveyors found that prescribed interventions, such as keeping the bed in a low position, using a fall mat, applying bright colored tape to the wheelchair, and providing a nonskid mat in the wheelchair, were not consistently in place. Additionally, the resident's call light was not always within reach, and the resident did not use it even when prompted, despite this being an intervention listed in the care plan. Interviews with staff indicated a lack of awareness and inconsistent knowledge of the resident's fall interventions. Some staff were unaware of specific interventions, and others noted that the resident rarely used the call light. The Director of Nursing confirmed that after each fall, a root cause analysis and new intervention should be implemented, but the care plan and records showed that this was not consistently done. Furthermore, the facility did not have a formal fall policy in place, contributing to the lack of consistent preventative measures and supervision for the resident.