Failure to Implement Fall Management Interventions and Alarm Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Management System policy for two residents identified as being at risk for falls. For one resident with dementia, severe cognitive impairment, and a physician’s order to apply a bed pad alarm whenever the resident was in bed due to poor safety awareness, surveyors observed the resident sitting at the edge of the bed while the bed sensor pad alarm unit was hanging on the nightstand with the switch in the off position. The resident’s care plan also specified that a pad alarm was to be applied whenever the resident was in bed. During a concurrent observation and interview, the Infection Preventionist confirmed that the alarm was off and stated that the alarm needed to be on in order to sound when the resident attempted to get out of bed unassisted. For another resident with metabolic encephalopathy, Alzheimer’s disease, type 2 diabetes mellitus, severe cognitive impairment, and dependence or substantial/maximal assistance needs for multiple ADLs, the facility’s Interdisciplinary Team did not implement new interventions after the resident experienced multiple falls, including falls on two specific documented dates. Post-Event IDT Review forms for those falls did not show any new interventions, and the Director of Nursing confirmed that new interventions should have been implemented to prevent further falls. The Director of Nursing also confirmed that the resident’s care plan was not updated following the falls on those dates, despite the facility’s Fall Management System policy requiring investigation of falls, documentation of recommendations in the clinical record, and updating of the resident’s care plan.
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