Failure to Investigate Falls and Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to thoroughly investigate and evaluate each resident fall to determine the cause and did not implement new or modify existing interventions to prevent future falls or reduce the risk of injury. Additionally, the care plans for residents with a history of falls were not updated to reflect current fall interventions, and there was no effective system in place to communicate these interventions to staff. These deficiencies were identified in three residents with a history of falls, all of whom experienced multiple incidents without adequate follow-up or documentation of interventions. One resident with severe cognitive impairment and a history of dementia experienced several falls, some resulting in injuries such as lacerations and hematomas. Despite physician orders for interventions like a soft helmet and floor mats, these were not consistently documented in the care plan or implemented by staff. Observations revealed that required safety equipment was sometimes missing or not used as ordered, and staff were unaware of current interventions due to outdated or missing communication tools. Interviews with CNAs indicated confusion about when and how to use fall prevention measures, and the Director of Nursing confirmed that interventions were not always added to care plans or communicated effectively. Another resident with moderately impaired cognition and a diagnosis of cancer experienced multiple falls, including incidents where the resident fell from bed or a wheelchair, sometimes sustaining injuries. Documentation of these events was inconsistent, and interventions such as fall mats were not always present or documented in the care plan. A third resident with severe cognitive impairment and mobility limitations also experienced a fall, but there was insufficient documentation regarding the circumstances of the fall or the use of safety equipment like side rails. The facility lacked a consistent process for post-fall investigation and failed to ensure that all staff were informed of and implemented appropriate fall prevention interventions.