Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and consistently maintain interventions to prevent future falls for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer's disease, legal blindness, abnormalities of gait and mobility, and lack of coordination, and was assessed as being at high risk for falls. The care plan included interventions such as promptly laying the resident down after meals, reclining the wheelchair for safety, and ensuring the wheelchair was locked and positioned under the table. Despite these documented interventions, the resident experienced multiple falls, including incidents where the wheelchair was not reclined as required and where staff were unsure about the use of foot pedals. On several occasions, the resident was found on the floor after falling from the wheelchair, sustaining injuries including lacerations to the face that required sutures. Staff interviews revealed inconsistent application of safety interventions, such as not reclining the wheelchair when transporting the resident and uncertainty about the use of foot pedals. The resident's physical condition, including contractures and a tendency to lean forward, further increased the risk of falls, yet interventions were not reliably implemented to address these risks. Facility records and staff statements indicated that the resident was unable to self-propel and was not educatable due to severe cognitive impairment. Despite being identified as high risk and having a care plan in place, the facility did not ensure that interventions were consistently followed, resulting in repeated falls and injuries. The facility's fall management policy required ongoing and consistent implementation of safety precautions for at-risk residents, which was not achieved in this case.