Failure to Assess and Address Root Causes of Repeated Falls
Penalty
Summary
The facility failed to comprehensively assess and address the root causes of repeated falls for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer's disease, diabetes mellitus, and Parkinson's disease, and was identified as high risk for falls due to a history of falls, psychoactive drug use, severe cognitive impairment, and incontinence. Despite multiple documented falls, the facility did not consistently conduct timely or thorough investigations into the causes of each incident, nor did they promptly revise the care plan to implement effective, ongoing interventions tailored to the resident's needs. Several fall incidents occurred, with reports indicating issues such as alarms not functioning properly, the resident's impulsivity, self-transfers, and incontinence. In multiple cases, immediate interventions were either not developed or not implemented, and care plan revisions were delayed. The interdisciplinary team (IDT) reviews often lacked comprehensive analysis of causal factors, particularly regarding the resident's impulsivity, compulsiveness, and failure to use the call light. Although some interventions were eventually added, such as family assistance and changes to alarm placement, these were not implemented in a timely manner and did not always address the underlying causes identified in the incident reviews. Interviews with staff, including an LPN and the DON, revealed a lack of awareness and understanding regarding the need for comprehensive root cause analysis and timely care plan updates following each fall. The facility's own protocol required identification of fall causes within 24 hours and ongoing evaluation of intervention effectiveness, but these procedures were not consistently followed. As a result, the resident continued to experience repeated falls without adequate assessment or modification of interventions to prevent recurrence.