Failure to Implement Effective Fall-Prevention Interventions and Post-Fall IDT Review
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate fall-prevention interventions and post-fall management for one resident identified as being at risk for falls. The resident had multiple diagnoses, including chronic pulmonary edema, cirrhosis of the liver, and morbid obesity, and was documented on the MDS as having short-term memory problems and severely impaired cognitive skills for daily decision-making. Functionally, the resident required substantial assistance with toileting, lower body dressing, transfers, and walking, and used a wheelchair with partial to moderate assistance for mobility. A Fall Risk Evaluation dated 10/17/2025 identified the resident as at risk for falls, and the care plan for risk of falls included general interventions such as assisting with ambulation and transfers, utilizing therapy recommendations, determining transfer ability, and initiating fall risk precautions if the resident was at risk. Despite these identified risks, the resident experienced four falls after admission: an unwitnessed fall on 12/27/2025 with a reported headache that led to an emergency room transfer; an unwitnessed fall on 1/23/2026 resulting in a laceration above the right eyebrow and a skin tear on the right forearm; a fall on 2/18/2026 where the resident was found lying on the floor on the right side; and another fall on 2/21/2026 where the resident was found on the floor between the bed and tray table with bleeding in the mouth and confusion, leading to transfer to a general acute care hospital. Care plans related to impaired physical mobility and actual injury from the first unwitnessed fall focused on neuro checks, physician notification, pain assessment, and hospital transfer, and later added a general directive to determine and address causative factors of the fall. After the fourth fall, additional broad interventions were documented, such as anticipating and meeting needs, ensuring call light within reach, appropriate footwear, following the fall protocol, reviewing past falls to determine causes, and educating the resident and IDT. The facility did not conduct post-fall IDT meetings with the primary physician or consult the pharmacist after any of the four falls, despite facility policies requiring IDT involvement and physician and pharmacist input in developing and revising comprehensive, person-centered care plans and fall-prevention interventions. The DON acknowledged awareness of the resident’s falls and stated that staff should have implemented new interventions such as rounding and assisting the resident as needed, and further stated that the interventions in the resident’s care plan would not prevent a fall and that the revised interventions would not prevent another fall. Facility policies on Person Centered Care Plan, Fall Prevention Program, and Comprehensive Plan of Care required identification of resident-specific risks and causes, development of realistic and specific goals and approaches, implementation of precautions according to the fall prevention program, and periodic review and revision of the care plan by the IDT, including the attending physician and consultant pharmacist. These policy requirements were not followed for this resident following the repeated fall incidents.
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