Failure to Investigate Falls, Update Care Plans, and Implement Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Prevention Program policy by not adequately investigating falls, not updating care plans with new interventions after falls, and not implementing existing fall interventions for multiple residents. The facility’s policy requires assessment of individual fall risk, implementation of appropriate interventions, notification of the physician and family, and care plan updates that address each fall with revised interventions as appropriate. Despite this, three residents with known fall risks experienced falls without proper follow-up, care plan revisions, or consistent implementation of basic safety measures such as call light access and appropriate footwear. One resident with metastatic lung cancer with brain involvement, history of TBI, seizures, malnutrition, and gait abnormalities was care planned as needing substantial/maximal assistance with toileting, transferring, and sitting, and was identified as at risk for falls. The care plan included interventions such as ensuring the call light was within reach and that the resident wore appropriate footwear when up. Nursing notes documented four falls within a three‑week period, including a witnessed fall from a wheelchair. During observation, this resident was found sitting in a wheelchair with bare feet on the floor, without socks or footwear, and the call light was across the room by the bed, not within reach, while the resident stated he needed to use the restroom and wanted his nurse. Another resident was identified on the care plan as high risk for falls due to cognitive impairment, confusion, incontinence, use of assistive devices, impaired judgment, decreased muscle coordination, history of falls, and medication side effects, with an intervention for call light within reach and prompt response. Nursing notes documented an unwitnessed fall and referenced a new intervention for nonskid footwear, but the current care plan did not show any new intervention added after that fall. Observation later showed this resident sitting in a recliner without a call light within reach and with no call light on that side of the room, which was confirmed by a CNA who stated the resident did not have a call light and should have one. A third resident with tracheostomy, gastrostomy, critical illness myopathy, a stage IV sacral pressure ulcer, type 2 diabetes, and a history of falls had a care plan stating the need for a low bed and floor mats, but after being found partially out of bed with the bed low, buttocks and legs on the floor, and a rectal tube pulled out, there was no documented fall investigation, no care plan revisions, and no updated fall assessment in the electronic record.
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