Failure to Address Repeated Non-Compliance with Fall Interventions
Penalty
Summary
The facility failed to implement appropriate interventions and adequately address repeated non-compliance with fall prevention measures for a resident with a history of falls and impaired cognition. The resident, who had diagnoses including dementia, diabetes, anxiety disorder, and glaucoma, was identified as being at risk for falls and required assistance with activities of daily living. The care plan included interventions such as keeping the call light within reach and ensuring the resident wore non-skid footwear when out of bed. Despite these interventions, the resident experienced multiple unwitnessed falls over several months, many of which were attributed to not wearing non-skid footwear. Fall investigations repeatedly documented that the resident was non-compliant with wearing non-skid footwear, and staff educated the resident on this intervention multiple times. However, the facility did not implement alternative or additional interventions to address the resident's ongoing non-compliance. Interviews with facility staff confirmed the resident's repeated non-compliance and the lack of new or modified interventions, despite the resident having numerous falls over an extended period. The facility's policy required review and modification of care plans following falls, but the interventions remained unchanged and ineffective.