Failure to Update Fall Prevention Interventions After Multiple Resident Falls
Penalty
Summary
A deficiency was identified when the facility failed to update and implement fall prevention interventions for a resident who experienced two falls in one day. The resident, who had diagnoses including dysphagia, weakness, anxiety, osteoarthritis, diabetes, and hypertension, was assessed as cognitively intact but required substantial to maximum assistance with activities of daily living. The care plan, established upon admission, identified the resident as being at risk for falls due to deconditioning and balance problems, with interventions such as maintaining a well-lit and clutter-free environment and keeping personal items within reach. However, after the resident experienced two separate falls in one day—one during therapy and another during a bathroom transfer—there were no updates or revisions made to the care plan to address these incidents. Facility policy required that the care plan be reviewed and updated following any fall. Despite this, the Assistant Director of Nursing Services confirmed that no new interventions were added to the care plan after the falls occurred. This lack of timely care plan revision and implementation of additional fall prevention measures constituted a failure to ensure adequate supervision and accident hazard prevention for the resident.