Failure to Complete Fall Interventions and Notify Family After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely follow-up on fall-related interventions and to notify a family member after a resident fall. For one resident with diabetes and dementia, a fall occurred in the resident’s room, and the immediate post-fall intervention included a request for an OT evaluation and bed mobility assessment. A physician’s order was signed several days later for an OT evaluation and treatment related to the resident rolling out of bed. However, the OT evaluation was not completed, and the Clinical Support Nurse was unable to locate documentation explaining why it was not done. For another resident with kidney disease and tachycardia, who was cognitively impaired and required staff assistance for transfers, a fall occurred in the resident’s room. The fall care plan indicated the resident needed assistance of two staff members for transfers. The incident documentation for the fall stated that the resident was their own responsible party under family/contact notification. During an interview, a family member reported being aware of only two falls during the resident’s stay, despite the facility’s fall policy requiring that the POA or other legal representative be notified when a resident experiences a fall and that a root cause analysis be conducted to plan appropriate interventions.
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