Failure to Identify Root Causes and Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to determine root causes of falls and implement appropriate interventions to prevent recurrence for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with dementia and exhibiting a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, experienced multiple falls during their stay. Despite the facility's policy requiring incident reports, fall scene investigations, and care plan updates after each fall, there were repeated lapses in updating the care plan with new or revised interventions following several of the resident's falls. On multiple occasions, the resident was found on the floor, sometimes with injuries such as lacerations and skin tears. Root causes identified in fall scene reports included impaired memory, gait imbalance, inappropriate footwear, and issues with physical coordination. However, interventions listed in these reports were not consistently added to the resident's care plan, and in some cases, no new interventions were developed at all. Interviews with facility leadership confirmed that interventions identified at the time of the fall were not always implemented long-term, and there was a lack of follow-through in updating the care plan to reflect new risks or strategies. Additionally, some interventions placed on the care plan were duplicative or ineffective, such as encouraging the use of a call light for a resident who was known not to use it due to cognitive impairment. The facility also failed to consistently determine the root cause of each fall, and in some cases, interventions were delayed or not implemented until months after the initial incident. These actions and inactions resulted in a failure to provide adequate supervision and accident hazard prevention as required by facility policy and regulatory standards.