Failure to Implement Fall Prevention Interventions and Complete Required Fall Investigation
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and that fall prevention interventions were in place, as required by facility policy. A resident with a history of falls, bilateral amputation, impaired mobility, and cognitive intactness was care planned to have a floor mat and Dycem in the wheelchair seat as fall interventions. On observation, the floor mat was not in place while the resident was in bed, and staff confirmed that it should have been present according to the care plan. The Director of Nursing acknowledged that the intervention was missing and that staff education would be initiated. Additionally, the resident experienced an incident where he was found outside the facility in his wheelchair, appeared intoxicated, and later was found on the floor in his room. Staff interviews and documentation revealed that after the resident was assessed and returned to bed, there was no mention of a fall in the progress notes, and the required fall investigation was not completed. The nurse involved did not document the fall or complete the necessary event documentation, fall risk assessment, or pain assessment as outlined in the facility's Falls Management Process policy. Furthermore, the physician was not updated regarding the fall, as required by facility policy. The only communication to the physician referenced the resident's intoxication and return to the facility, with no mention of the fall event. The Director of Nursing confirmed that a fall investigation should have been completed and that the physician should have been notified, but these actions were not taken at the time of the incident.