Failure to Complete Timely IDT Post-Fall Assessment and Implement Fall-Prevention Interventions
Penalty
Summary
Surveyors identified a failure by the facility to ensure timely, comprehensive IDT post-fall assessments, root cause analyses, and implementation and documentation of fall-prevention interventions for a resident with multiple falls. The resident was admitted after a hospitalization for a right iliac crest fracture and had diagnoses including osteopenia, degenerative changes, altered mental status, dementia, cognitive decline, weight loss, and lethargy, with documentation that her cognitive decline had progressed rapidly over the prior month. Nursing notes showed the resident experienced three falls: the first occurred when she attempted to park her wheeled walker without locking the brakes and fell on her right knee and hip; the second was an unwitnessed fall resulting in bruising to the right elbow and hip; and the third was an unwitnessed fall resulting in a facial laceration, hematoma to the left brow, a skin tear to the left elbow, decreased level of consciousness, and transfer to the hospital. During this period, the resident was also placed on palliative care and tested positive for COVID-19. Interviews with staff revealed that IDT post-fall assessments were typically completed within 24 hours and used to identify root causes and interventions, with care plans updated as needed, but staff acknowledged that IDT meetings for this resident did not occur in a timely manner. The IDT post-fall note for the first fall, which was not dated until nearly two weeks later, identified root causes related to improper walker use and short-term memory deficits, and listed interventions such as more frequent visual checks, consistent cueing for safe walker handling, evaluation of the walker, and continued OT/PT with a focus on fall prevention. However, review of the electronic health record and the resident’s care plan showed no evidence that these interventions were implemented or added to the care plan before the resident’s subsequent falls and hospitalization. This was inconsistent with the facility’s own Fall Response & Management policy, which required evaluation of causal factors after a fall, review and updating of the care plan with individualized measures, and IDT review and placement of interventions following fall incidents.
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