Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to follow the plan of care for a resident with a known history of falls, resulting in multiple incidents where the resident fell and sustained serious injuries. The resident had diagnoses including dementia, traumatic subarachnoid hemorrhage, conversion disorder with seizures, and other neurological and psychiatric conditions. Assessments indicated the resident required a walker for ambulation and needed staff assistance or supervision while moving or walking. The care plan specified that staff should keep the walker within the resident's reach and apply non-skid socks at bedtime. However, documentation showed that these interventions were not consistently implemented, and there was no record of the resident refusing these interventions. Following a fall on 10/10, the care plan was not updated with new preventative interventions until several days later, despite the resident not using the walker at the time of the fall. Another fall occurred on 10/16, again with the resident not using the walker and not wearing non-skid socks, and no new interventions were added to the care plan. Additional falls occurred in the following weeks, including a significant incident in the dining room where the resident got up without assistance or a walker, fell, and suffered a seizure. The care plan intervention to keep the walker within reach was not applied in the dining room, and staff moved the walker out of reach due to concerns it might be a tripping hazard for others. Interviews with facility leadership revealed a lack of awareness regarding the need to update the care plan after each fall and uncertainty about the application of interventions in different facility areas. The facility did not have a policy for following care plan interventions at the time, and documentation of intervention refusals was lacking. The failure to implement and update fall prevention interventions as required by the care plan led to repeated falls and ultimately resulted in the resident sustaining multiple traumatic injuries, including hemorrhages and a skull fracture.