Failure to Implement New Fall Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document new fall-prevention interventions after falls for a resident who was assessed as high fall risk upon admission. The resident had dementia, osteoarthritis, cognitive impairment, a history of falls, and used a wheelchair. The care plan, initiated and revised over time, identified the resident as high risk for falls with goals that the resident would be free of falls and not sustain serious injury. A fall risk assessment documented the resident as high risk. Despite this, the resident experienced multiple falls, and the interventions added to the care plan did not represent new or progressive measures between falls as required by facility policy. On one occasion, a progress note documented that staff responded to yelling and found the resident lying on the floor in her room, with her feet facing the door and entangled in the bottom of an isolation bin, her wheelchair unlocked next to her legs, and water spilled on the floor from a basin near her head. The resident was wearing regular socks without shoes, and the call light was on the bed and not in use. The resident reported she was trying to get in her car and thought she may have fallen. She complained of bilateral lower extremity pain, and neuro checks were initiated. Following this fall, the care plan intervention documented was to ensure non-skid socks were on the resident. Subsequently, the resident had another unwitnessed fall, resulting in a new skin tear on the left elbow. The care plan intervention documented after this fall was to remind the resident to wear non-skid footwear and remind staff to make sure she had them on when needed. Later, the resident sustained another unwitnessed fall, where staff found her sitting on the floor in front of her dresser with two bottom drawers on the floor, her wheelchair unlocked in the corner, her walker next to the bed, and wearing regular socks and a brief. She had a skin tear to the left hand, a hematoma to the left side of the forehead, and complained of head and bilateral knee/hip pain. Neuro checks showed eyes slow to react and slurred speech. She was transferred to the ED, where imaging revealed two rib fractures. Interviews with the DON and NP confirmed that post-fall interventions are expected to be new, progressive, and documented on the care plan, and the facility’s fall policy requires additional or different interventions when falls recur, which did not occur in this case.
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