Failure to Implement Safety Interventions and Therapy Evaluations After Multiple Resident Falls
Penalty
Summary
The facility failed to implement appropriate safety interventions and complete therapy evaluations for cognitively impaired residents who experienced multiple falls. According to the facility's Fall Reduction policy, residents at risk for falls should receive a therapy screen, and care plans should be reviewed and updated after each fall. However, two residents with a history of falls did not receive therapy evaluations after repeated incidents, and their care plans were not adequately updated with effective interventions. One resident with dementia and poor safety awareness experienced three falls within a 24-day period, resulting in a left foot fracture. The resident was found on the floor multiple times, often attempting to go to the bathroom independently, and was observed without gripper socks or with the bed not in the lowest position. Staff interviews revealed that the resident was confused, especially at night, and unable to remember to use the call light. Despite these risks, the resident's care plan continued to document independence with transfers and mobility, and no therapy evaluation was completed after the falls. Another resident, admitted for rehabilitation after a fall at home, experienced a decline in condition after multiple falls in the facility. This resident sustained a displaced rib fracture and right radial neck fracture following an unwitnessed fall and was subsequently placed on hospice care. Documentation and interviews indicated that the resident was initially alert and oriented but became increasingly unsteady and confused after repeated falls. The call light system in the resident's room was reported as nonfunctional, and there was no evidence of a therapy evaluation or effective intervention following the falls.