Failure to Implement Effective Fall Prevention Program and Inadequate Post-Fall Response
Penalty
Summary
The facility failed to implement and maintain an effective fall prevention program, as evidenced by multiple incidents involving residents who experienced falls resulting in injuries, including fractures and lacerations. In several cases, staff did not complete required fall checklists or event forms, and there was a lack of timely and thorough nursing assessments following fall events. For example, one resident experienced a fall in the bathroom resulting in a rib fracture, but no fall checklist was completed, and there were no nursing progress notes documenting assessments of the resident's condition in the days following the incident. Another resident with a history of multiple falls, cognitive impairment, and high-risk medications experienced several falls, some resulting in head lacerations and bruising. The care plan for this resident was not updated to reflect new risks or interventions after each fall, and interventions such as fall or bed alarms were not considered or implemented. Staff interviews revealed inconsistent understanding and application of fall prevention protocols, and care plans often contained outdated or irrelevant interventions. Additionally, there was a lack of individualized interventions addressing specific risk factors such as incontinence and confusion. Further review showed that staff were not consistently trained or updated on fall prevention interventions, and communication regarding residents' fall risk was inadequate. Assignment sheets and room signage did not reliably indicate which residents were at high risk for falls. In some cases, falls were not investigated or discussed by the interdisciplinary team, and root cause analyses were not completed. Facility policies required comprehensive post-fall management and care plan updates, but these were not consistently followed, resulting in repeated falls and injuries among residents.