Failure to Implement Individualized Fall Prevention and Supervision
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized, and effective fall prevention program for two residents identified as being at risk for falls. One resident, who was a new admission with a history of falls, cognitive impairment, and multiple comorbidities, experienced multiple unwitnessed falls, including one that resulted in a cervical fracture and intracranial hemorrhage, ultimately leading to death. Despite being assessed as high risk for falls, the resident's care plan and bedside Kardex lacked specific, individualized interventions to address his supervisory needs and did not reflect changes after each fall. The interventions in place, such as gripper socks and a low bed, were generic and not tailored to the resident's evolving condition or behaviors, such as confusion and restlessness. Documentation was inconsistent, and there was no evidence of interdisciplinary coordination or timely updates to the care plan following each incident. The facility's investigation and documentation of falls were incomplete. For several falls, there were missing or inadequate staff witness statements, lack of detailed incident reports, and insufficient information regarding the circumstances and interventions in place at the time of each fall. Staff interviews revealed a lack of clarity regarding individualized fall interventions, with some staff relying on standard protocols rather than resident-specific needs. Supervisory needs, particularly when the resident was in common areas, were not addressed in the care plan or consistently implemented, resulting in periods where the resident was left unsupervised despite being identified as needing increased supervision. A second resident, also at risk for falls and with cognitive impairment, was observed in a standard wheelchair rather than the prescribed tilt-in-space wheelchair, contrary to physician orders and the care plan. This deviation from the care plan was confirmed by staff and indicated a failure to ensure that planned fall safety interventions were in place. The facility's fall management policy required individualized assessment and intervention, but in practice, interventions were not consistently individualized or implemented as planned for residents at risk for falls.