Failure to Follow Fall Prevention Policy and Implement Post-Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention policy and ensure residents’ environments were free from accident hazards. The policy required fall risk assessments every 90 days and with changes in condition, with nurses to identify fall risk and initiate care plan interventions accordingly. For one resident with severe cognitive impairment who was dependent on staff for daily care and transfers, a fall on September 24, 2025 led to the addition of a weighted blanket as a new intervention to decrease anxiety and restlessness, and the care plan was updated to reflect this. However, the clinical record showed fall risk assessments were only completed on January 2 and September 5, 2025, with no evidence of 90‑day reassessments as required. On observation in February 2026, the resident was in bed without the ordered weighted blanket, and the LPN caring for the resident stated she was not aware that the resident was supposed to have a weighted blanket. The Nursing Home Administrator confirmed that fall risk assessments should have been completed every 90 days and that the resident should have had a weighted blanket. The deficiency also includes the facility’s failure to complete a thorough post‑fall investigation and implement fall interventions for another resident. This resident was cognitively impaired, had dementia, a history of falls, was dependent with transfers, and used a pivot disc with two‑person assistance for transfers. A nursing note documented that the resident experienced an assisted fall during a transfer from a recliner to bed when he became weak and was lowered to the floor and then assisted to bed for evening care. The incident report for this fall indicated there were no witness statements and no fall investigation completed to identify contributing factors. There was no documentation that staff transfer technique was evaluated or that any new fall interventions were implemented after the fall to minimize the risk of further falls. The DON confirmed there were no witness statements, no further investigation reports, and no documented evidence of post‑fall interventions for this resident.
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