Failure to Ensure Accurate Fall Prevention Documentation and Interventions
Penalty
Summary
The facility failed to ensure that interventions to prevent falls were properly implemented and documented for a resident identified as high risk for falls. The resident, who had diagnoses including osteoporosis, glaucoma, and generalized muscle weakness, was readmitted with a high fall risk score. The care plan included interventions such as keeping the bed in the lowest position, placing floor mats next to the bed, and maintaining a hazard-free environment. Despite these interventions, the resident experienced an unwitnessed fall. Upon review, it was found that the SBAR Communication Form and Incident Note related to the fall were incomplete and inaccurate. Specifically, the SBAR form did not include the physician's recommendations, and neither the SBAR nor the Incident Note provided clear details on how the fall occurred. Additionally, the Interdisciplinary Care Conference documentation was inconsistent, with conflicting information about whether the fall was witnessed and lacking specific details about the incident. The Director of Nursing acknowledged during an interview that the documentation across the SBAR, Incident Note, and IDT did not match and failed to provide essential information regarding the circumstances of the fall. Facility policies required nursing documentation to be concise, clear, pertinent, and accurate, and for investigations to identify contributing factors to falls. The lack of accurate and complete documentation had the potential to impact the staff's ability to implement appropriate interventions for the resident.